Accessibility of Opioid Treatment Programs Based on Conventional vs Perceived Travel Time Measures.

Importance: Transportation barriers have long been associated with poorer health outcomes; this burden is especially acute for individuals with opioid use disorder (OUD), a chronic disease often associated with low socioeconomic status. Conventional travel time analyses may not fully account for experiential components of travel, thereby understating the true travel burden and overstating treatment accessibility to opioid treatment programs (OTPs). Objective: To develop a metric of feels-like accessibility for those using public transit to access OTPs that accounts for the realistic travel burden on individuals with OUD. Design, Setting, and Participants: This cross-sectional study integrated high-resolution transit schedules and operating hours of OTPs to measure feels-like accessibility. Feels-like accessibility considers the differential outcomes of out-of-vehicle travel components and more realistically reflects individuals' transportation burden than conventional accessibility measures. Gini indices and spatial regression models were used to investigate inequities in accessibility. Geocoded data for residential addresses of 1018 overdose fatalities in Connecticut in 2019 were used as a proxy for the treatment needs of individuals with OUD. Data were analyzed between May and August 2023. Main Outcomes and Measures: Conventional and feels-like accessibility scores. Exposures: Fluctuations in public transit frequencies over the course of the day and the limited operating hours of the OTPs. Results: Of the 1018 individuals in the study, the mean (SD) age at death was 43.7 (12.6) years, 784 individuals (77%) were men, 111 (11%) were African American, and 889 (87%) were White, with other racial and ethnic categories including 18 individuals (2%). A total of 264 individuals in the sample (26%) could not access an OTP within 180 minutes. For those who could access these facilities, the average 1-way travel time was 45.6 minutes, with individuals spending approximately 70% of their trip duration on out-of-vehicle travel components. The conventional accessibility metric underestimates individuals' travel burden to OTPs as well as the inequity in accessibility compared with the feels-like accessibility metric. For example, the median (range) conventional accessibility score, defined as the number of OTPs within 120 minutes of transit travel time, was 5.0 (0.0-17.0); the median (range) feels-like accessibility score, defined as the number of OTPs within 120 minutes of transit travel time weighted to account for in- and out-of-vehicle segments, was 1.0 (0.0-10.0). There is a considerable temporal variation in travel time and accessibility depending on the departure times. Conclusions and Relevance: In this cross-sectional study of travel burdens, the calculated feels-like accessibility scores, which consider the differential outcomes of out-of-vehicle travel components (eg, walking and waiting), could better and more realistically reflect passengers' transportation burden. Policy recommendations derived from the conventional accessibility metric could be misleading, and decision-makers should use feels-like accessibility metrics that adequately capture individuals' travel burdens. In the context of access to OTPs, the findings from this study suggest that opening new OTP sites to address gaps in access due to distance to services or extending hours of operation at existing sites may ameliorate the travel burden for individuals.

Trusted residents and housing assistance to decrease violence exposure in New Haven (TRUE HAVEN): a strengths-based and community-driven stepped-wedge intervention to reduce gun violence.

BACKGROUND: We describe the rationale and study design for "TRUsted rEsidents and Housing Assistance to decrease Violence Exposure in New Haven (TRUE HAVEN)," a prospective type 1 hybrid effectiveness/implementation study of a multi-level intervention using a stepped wedge design. TRUE HAVEN aims to lower rates of community gun violence by fostering the stability, wealth, and well-being of individuals and families directly impacted by incarceration through the provision of stable housing and by breaking the cycle of trauma. DESIGN: TRUE HAVEN is an ongoing, multi-level intervention with three primary components: financial education paired with housing support (individual level), trauma-informed counseling (neighborhood level), and policy changes to address structural racism (city/state level). Six neighborhoods with among the highest rates of gun violence in New Haven, Connecticut, will receive the individual and neighborhood level intervention components sequentially beginning at staggered 6-month steps. Residents of these neighborhoods will be eligible to participate in the housing stability and financial education component if they were recently incarcerated or are family members of currently incarcerated people; participants will receive intense financial education and follow-up for six months and be eligible for special down payment and rental assistance programs. In addition, trusted community members and organization leaders within each target neighborhood will participate in trauma-informed care training sessions to then be able to recognize when their peers are suffering from trauma symptoms, to support these affected peers, and to destigmatize accessing professional mental health services and connect them to these services when needed. Finally, a multi-stakeholder coalition will be convened to address policies that act as barriers to housing stability or accessing mental healthcare. Interventions will be delivered through existing partnerships with community-based organizations and networks. The primary outcome is neighborhood rate of incident gun violence. To inform future implementation and optimize the intervention package as the study progresses, we will use the Learn As You Go approach to optimize and assess the effectiveness of the intervention package on the primary study outcome. DISCUSSION: Results from this protocol will yield novel evidence for whether and how addressing structural racism citywide leads to a reduction in gun violence. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05723614. Registration date: February 01, 2023. Please refer to https://clinicaltrials.gov/ct2/show/NCT05723614 for public and scientific inquiries.

The Association of Sacro-Femoro-Pubic Angle and Postoperative Dislocation Following Total Hip Arthroplasty.

BACKGROUND: Spino-pelvic orientation may affect dislocation risk following total hip arthroplasty (THA). It can be measured on lateral lumbo-pelvic radiographs. The sacro-femoro-pubic (SFP) angle, measured on an antero-posterior (AP) pelvis radiograph, is a reliable proxy for pelvic tilt, a measurement of spino-pelvic orientation measured on a lateral lumbo-pelvic radiograph. The purpose of this study was to investigate the relationship between SFP angle and dislocation following THA. METHODS: An Institutional Review Board-approved retrospective case-control study was conducted at a single academic center. We matched 71 dislocators (cases) to 71 nondislocators (controls) following THA performed by 1 of 10 surgeons between September 2001 and December 2010. Two authors (readers) independently calculated SFP angle from single preoperative AP pelvis radiographs. Readers were blinded to cases and controls. Conditional logistic regressions were used to identify factors differentiating cases and controls. RESULTS: The data did not show a clinically relevant or statistically significant difference in SFP angles after adjusting for gender, American Society of Anesthesiologists classification, prosthetic head size, age at time of THA, measurement laterality, and surgeon. CONCLUSION: We did not find an association between preoperative SFP angle and dislocation following THA in our cohort. Based on our data, SFP angle as measured on a single AP pelvis radiograph should not be used to assess dislocation risk prior to THA.

TRUsted rEsidents and Housing Assistance to decrease Violence Exposure in New Haven (TRUE HAVEN): A strengths-based and community-driven stepped-wedge intervention to reduce gun violence.

Background We describe the rationale and study design for " TRU sted r Esidents and H ousing A ssistance to decrease V iolence E xposure in N ew Haven (TRUE HAVEN)," a prospective type 1 hybrid effectiveness/implementation study of a multi-level intervention using a stepped wedge design. TRUE HAVEN aims to lower rates of community gun violence by fostering the stability, wealth, and well-being of individuals and families directly impacted by incarceration through the provision of stable housing and by breaking the cycle of trauma. Design: TRUE HAVEN is a multi-level intervention with three primary components: financial education paired with housing support (individual level), trauma-informed counseling (neighborhood level), and policy changes to address structural racism (city/state level). Six neighborhoods with among the highest rates of gun violence in New Haven, Connecticut, will receive the individual and neighborhood level intervention components sequentially beginning at staggered 6-month steps. Residents of these neighborhoods will be eligible to participate in the housing stability and financial education component if they were recently incarcerated or are family members of currently incarcerated people; participants will receive intense financial education and follow-up for six months and be eligible for special down payment and rental assistance programs. In addition, trusted community members and organization leaders within each target neighborhood will participate in trauma-informed care training sessions to then be able to recognize when their peers are suffering from trauma symptoms, to support these affected peers, and to destigmatize accessing professional mental health services and connect them to these services when needed. Finally, a multi-stakeholder coalition will be convened to address policies that act as barriers to housing stability or accessing mental healthcare. Interventions will be delivered through existing partnerships with community-based organizations and networks. The primary outcome is neighborhood rate of incident gun violence. To inform future implementation and optimize the intervention package as the study progresses, we will use the Learn As You Go approach to optimize and assess the effectiveness of the intervention package on the primary study outcome. Discussion Results from this protocol will yield novel evidence for whether and how addressing structural racism citywide leads to a reduction in gun violence. Trial registration ClinicalTrials.gov Identifier: NCT05723614. Registration date: February 01, 2023.

Patterns of Infectious Disease Associated With Injection Drug Use in Massachusetts.

BACKGROUND: Since 2014, multiple outbreaks of human immunodeficiency virus (HIV) among people who inject drugs have occurred across the United States along with hepatitis C virus (HCV), skin and soft tissue infections (SSTIs), and infective endocarditis (IE), creating a converging public health crisis. METHODS: We analyzed the temporal patterns of infectious disease and overdose using a hierarchical Bayesian distributed lag logistic regression model examining the probability that a given geographic area experienced at least 1 HIV case in a given month as a function of the counts/rates of overdose, HCV, SSTI, and IE and associated medical procedures at different lagged time periods. RESULTS: Current-month HIV is associated with increasing HCV cases, abscess incision and drainage, and SSTI cases, in distinct temporal patterns. For example, 1 additional HCV case occurring 5 and 7 months previously is associated with a 4% increase in the odds of observing at least 1 current-month HIV case in a given locale (odds ratios, 1.04 [90% credible interval {CrI}: 1.01-1.10] and 1.04 [90% CrI: 1.00-1.09]). No such associations were observed for echocardiograms, IE, or overdose. CONCLUSIONS: Lagged associations in other infections preceding rises in current-month HIV counts cannot be described as predictive of HIV outbreaks but may point toward newly discovered epidemics of injection drug use and associated clinical sequalae, prompting clinicians to screen patients more carefully for substance use disorder and associated infections.

Estimating deaths averted and cost per life saved by scaling up mRNA COVID-19 vaccination in low-income and lower-middle-income countries in the COVID-19 Omicron variant era: a modelling study.

OBJECTIVES: While almost 60% of the world has received at least one dose of COVID-19 vaccine, the global distribution of vaccination has not been equitable. Only 4% of the population of low-income countries (LICs) has received a full primary vaccine series, compared with over 70% of the population of high-income nations. DESIGN: We used economic and epidemiological models, parameterised with public data on global vaccination and COVID-19 deaths, to estimate the potential benefits of scaling up vaccination programmes in LICs and lower-middle-income countries (LMICs) in 2022 in the context of global spread of the Omicron variant of SARS-CoV2. SETTING: Low-income and lower-middle-income nations. MAIN OUTCOME MEASURES: Outcomes were expressed as number of avertable deaths through vaccination, costs of scale-up and cost per death averted. We conducted sensitivity analyses over a wide range of parameter estimates to account for uncertainty around key inputs. FINDINGS: Globally, universal vaccination in LIC/LMIC with three doses of an mRNA vaccine would result in an estimated 1.5 million COVID-19 deaths averted with a total estimated cost of US$61 billion and an estimated cost-per-COVID-19 death averted of US$40 800 (sensitivity analysis range: US$7400-US$81 500). Lower estimated infection fatality ratios, higher cost-per-dose and lower vaccine effectiveness or uptake lead to higher cost-per-death averted estimates in the analysis. CONCLUSIONS: Scaling up COVID-19 global vaccination would avert millions of COVID-19 deaths and represents a reasonable investment in the context of the value of a statistical life. Given the magnitude of expected mortality facing LIC/LMIC without vaccination, this effort should be an urgent priority.

Similar 20-year survivorship for single and bilateral total knee arthroplasty.

BACKGROUND: Long-term follow-up after total knee arthroplasty (TKA) is crucial to providing survivorship updates on available TKA implants to guide patient expectations when undergoing TKA. The purpose of this study was to compare implant survivorship between patients undergoing primary single, simultaneous bilateral, and staged bilateral TKA with 15-year minimum follow-up. METHODS: This retrospective study included 826 patients (n = 1089) who underwent primary single (n = 454), simultaneous bilateral (n = 266), or staged bilateral (n = 369) TKA using a single TKA system by a single surgeon from 1991-2005 with 15-year minimum follow-up. Demographics, clinical variables, and surgical outcomes were collected and compared using Student's t-test, chi-squared tests, or Kaplan-Meier analyses. Reoperation was defined as all surgeries performed on the knee after the index procedure; revision TKA was defined as complete implant exchange. p < 0.05 significant. RESULTS: Patients in the staged TKA cohort were younger (65.4 years = staged, 67.8 = simultaneous, 67.1 = single, p < 0.019). Women were less likely to receive simultaneous TKAs (22 %vs.29%, p < 0.001). Postoperative range of motion was similar (116.8° = simultaneous, 114.9° = staged, 114.8° = single, p = 0.11). Overall 15-year implant survival based on revision TKA was similar (97.7% = simultaneous, 97.2% = staged, 96.7% = single, p = 0.45). The estimated 15-year reoperation rate was 7.0% (95% CI, 5.5-8.7%). Reoperations were secondary to infection (35.5%), implant wear (26.3%), arthrofibrosis (18.4%), traumatic injuries (10.5%), pain (6.6%), pathologic lesion (1.3%), and avascular necrosis (1.3%). CONCLUSION: This study demonstrated a high implant survival rate of 95-97% at 20-years after primary single, staged bilateral and simultaneous bilateral TKA. Furthermore, simultaneous bilateral TKAs exhibited similar range of motion, implant survival, and rates of reoperation to staged bilateral and single TKA.

Adventures in COVID-19 Policy Modeling: Education Edition.

PURPOSE OF REVIEW: To introduce readers to policy modeling, a multidisciplinary field of quantitative analysis, primarily used to help guide decision-making. This review focuses on the choices facing educational administrators, from K-12 to universities in the USA, as they confronted the COVID-19 pandemic. We survey three key model-based approaches to mitigation of SARS-CoV-2 spread in schools and on university campuses. RECENT FINDINGS: Frequent testing, coupled with strict attention to behavioral interventions to prevent further transmission can avoid large outbreaks on college campuses. K-12 administrators can greatly reduce the risks of severe outbreaks of COVID-19 in schools through various mitigation measures including classroom infection control, scheduling and cohorting strategies, staff and teacher vaccination, and asymptomatic screening. Safer re-opening of college and university campuses as well as in-person instruction for K-12 students is possible, under many though not all epidemic scenarios if rigorous disease control and screening programs are in place.

The Dynamics of Infectious Diseases Associated With Injection Drug Use in Lawrence and Lowell, Massachusetts.

BACKGROUND: There are a wide variety of infectious complications of injection drug use. Understanding the trajectory of these complications might inform the development of an early warning system for human immunodeficiency virus (HIV) outbreaks that occur regularly among people who inject drugs (PWID). METHODS: A distributed lag Poisson regression model in the Bayesian setting was used to examine temporal patterns in the incidence of injection-associated infectious diseases and their association with HIV cases in Lawrence and Lowell, Massachusetts between 2005 and 2018. RESULTS: Current-month HIV counts are associated with fatal overdoses approximately 8 months prior, cases of infective endocarditis 10 months prior, and cases of skin and soft tissue infections and incision and drainage procedures associated with these infections 12 months prior. CONCLUSIONS: Collecting data on these other complications associated with injection drug use by public health departments may be important to consider because these complications may serve as input to a sentinel system to trigger early intervention and avert potential outbreaks of HIV.

Maximizing the Efficiency of Active Case Finding for SARS-CoV-2 Using Bandit Algorithms.

Even as vaccination for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) expands in the United States, cases will linger among unvaccinated individuals for at least the next year, allowing the spread of the coronavirus to continue in communities across the country. Detecting these infections, particularly asymptomatic ones, is critical to stemming further transmission of the virus in the months ahead. This will require active surveillance efforts in which these undetected cases are proactively sought out rather than waiting for individuals to present to testing sites for diagnosis. However, finding these pockets of asymptomatic cases (i.e., hotspots) is akin to searching for needles in a haystack as choosing where and when to test within communities is hampered by a lack of epidemiological information to guide decision makers' allocation of these resources. Making sequential decisions with partial information is a classic problem in decision science, the explore v. exploit dilemma. Using methods-bandit algorithms-similar to those used to search for other kinds of lost or hidden objects, from downed aircraft or underground oil deposits, we can address the explore v. exploit tradeoff facing active surveillance efforts and optimize the deployment of mobile testing resources to maximize the yield of new SARS-CoV-2 diagnoses. These bandit algorithms can be implemented easily as a guide to active case finding for SARS-CoV-2. A simple Thompson sampling algorithm and an extension of it to integrate spatial correlation in the data are now embedded in a fully functional prototype of a web app to allow policymakers to use either of these algorithms to target SARS-CoV-2 testing. In this instance, potential testing locations were identified by using mobility data from UberMedia to target high-frequency venues in Columbus, Ohio, as part of a planned feasibility study of the algorithms in the field. However, it is easily adaptable to other jurisdictions, requiring only a set of candidate test locations with point-to-point distances between all locations, whether or not mobility data are integrated into decision making in choosing places to test.

Expanding access to methadone treatment in Ohio through federally qualified health centers and a chain pharmacy: A geospatial modeling analysis.

BACKGROUND: In the United States, methadone provision for opioid use disorder (OUD) occurs at opioid treatment programs (OTPs). Ohio recently enacted a policy to expand methadone administration to Federally Qualified Health Centers (FQHC). We compared how the provision of methadone at current OTPs or the proposed expansion to FQHCs and pharmacies meets the urban and rural need for OUD treatment. METHODS: Cross-sectional geospatial analysis of zip codes within Ohio with at least one 2017 opioid overdose death stratified by Rural-Urban Commuting Area codes. Our primary outcome was the proportion of need by zip code (using opioid overdose deaths as a proxy for need) within a 15- or 30- minute drive time of an OTP. RESULTS: Among 581 zip codes, sixty four percent of treatment need was within a 15-minute drive time and 81 %, within a 30-minute drive time. The proportion of need within a 15-minute drive decreased with increasing rural classification (urban 78 %, suburban 20 %, large rural 9%, and small rural 1%;p<.001). The portion of need within a 15-minute drive time increased with the addition of FQHCs (96 %) and the addition of chain pharmacies (99 %) relative to OTPs alone among all zip codes and for all urban-rural strata (p<.001). CONCLUSION: Over one-third of OUD treatment need was not covered by existing OTPs and coverage decreased with rural classification of zip codes. Most of the gap between supply and need could be mitigated with FQHC methadone provision, which would expand both urban and rural access.

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.

Short-Term Surgical Missions: Role of Pharmacist Volunteers.

Health care professionals often participate in short-term surgical missions in underserved areas of the world. Surgical missions often rely on the use of medications to provide health care to these underserved areas in patients with multiple comorbid conditions. The direct role a pharmacist may have in surgical missions is not well described in the literature; however, numerous opportunities exist for pharmacist involvement to improve patient care and operational processes throughout medication planning and delivery of surgical missions. Pharmacists have specialized knowledge in medication acquisition, preparation, and distribution that result in a unique position to contribute positively to the mission's clinical and operational dynamics. Pharmacists may assist in various activities such as medication ordering, accrual, purchasing and preparing during the surgical mission. Pharmacists may also provide clinical support and offer alternative medications in the setting of drug intolerance or allergies. In 2008, Operation Walk Boston, a short-term surgical mission was established to provide hip and knee joint replacements to patients in the Dominican Republic. Pharmacists and pharmacy residents play a crucial role as members of this surgical mission. Based on our experience, this article aims to describe the evolving role of pharmacists as a member of a surgical mission.

Notch signalling drives synovial fibroblast identity and arthritis pathology.

The synovium is a mesenchymal tissue composed mainly of fibroblasts, with a lining and sublining that surround the joints. In rheumatoid arthritis the synovial tissue undergoes marked hyperplasia, becomes inflamed and invasive, and destroys the joint1,2. It has recently been shown that a subset of fibroblasts in the sublining undergoes a major expansion in rheumatoid arthritis that is linked to disease activity3-5; however, the molecular mechanism by which these fibroblasts differentiate and expand is unknown. Here we identify a critical role for NOTCH3 signalling in the differentiation of perivascular and sublining fibroblasts that express CD90 (encoded by THY1). Using single-cell RNA sequencing and synovial tissue organoids, we found that NOTCH3 signalling drives both transcriptional and spatial gradients-emanating from vascular endothelial cells outwards-in fibroblasts. In active rheumatoid arthritis, NOTCH3 and Notch target genes are markedly upregulated in synovial fibroblasts. In mice, the genetic deletion of Notch3 or the blockade of NOTCH3 signalling attenuates inflammation and prevents joint damage in inflammatory arthritis. Our results indicate that synovial fibroblasts exhibit a positional identity that is regulated by endothelium-derived Notch signalling, and that this stromal crosstalk pathway underlies inflammation and pathology in inflammatory arthritis.

Cost-effectiveness of dental antibiotic prophylaxis in total knee arthroplasty recipients with type II diabetes mellitus.

Objective: Type II diabetes mellitus (T2DM) is prevalent in knee osteoarthritis (OA) patients undergoing total knee arthroplasty (TKA) and increases risk for prosthetic joint infection (PJI). We examined the cost-effectiveness of antibiotic prophylaxis (AP) before dental procedures to reduce PJI in TKA recipients with T2DM. Design: We used the Osteoarthritis Policy Model, a validated computer simulation of knee OA, to compare two strategies among TKA recipients with T2DM (mean age 68 years, mean BMI 35.4 kg/m2): 1) AP before dental procedures and 2) no AP. Outcomes included quality-adjusted life expectancy (QALE) and lifetime medical costs. We used published efficacy of AP. We report incremental cost-effectiveness ratios (ICERs) and considered strategies with ICERs below well-accepted willingness-to-pay (WTP) thresholds cost-effective. We conducted sensitivity analyses to examine the robustness of findings to uncertainty in model input parameters. We used a lifetime horizon and healthcare sector perspective. Results: We found that AP added 1.0 quality-adjusted life-year (QALY) and $66,000 for every 1000 TKA recipients with T2DM, resulting in an ICER of $66,000/QALY. In sensitivity analyses, reduction of the probability of PJI, T2DM-associated risk of infection, or attribution of infections to dental procedures by 50% resulted in ICERs exceeding $100,000/QALY. Probabilistic sensitivity analyses showed that AP was cost-effective in 32% and 58% of scenarios at WTP of $50,000/QALY and $100,000/QALY, respectively. Conclusions: AP prior to dental procedures is cost-effective for TKA recipients with T2DM. However, the cost-effectiveness of AP depends on the risk of PJI and efficacy of AP in this population.

Veterans' compensation claims beliefs predict timing of PTSD treatment use relative to compensation and pension exam.

INTRODUCTION: In this study we developed the Disability Beliefs Scale to assess Veterans' beliefs that engaging in treatment, as well as other behaviors, would affect the likelihood of a Veteran's being awarded disability-related benefits. We posited that Veterans with stronger beliefs that attending mental health treatment would facilitate a service-connection award would be more likely to attend PTSD treatment before their compensation and pension examinations for PTSD. METHODS: Electronic health records for 307 post-9/11-era Veterans applying for compensation and pension for service-connected PTSD and engaging in a clinical trial of a treatment-referral intervention were analyzed for PTSD-specific and more general mental health treatment use around the time of their compensation examinations. All participants completed the Disability Beliefs Scale and other baseline assessments. Multilevel models assessed change in treatment use as a function of time relative to the C&P exam, compensation examination status (before or after), and the interaction between examination status and beliefs about treatment benefits. RESULTS: No main effects of time or examination status were observed. As hypothesized, beliefs about treatment benefits moderated the effect of examination status on PTSD treatment use. Veterans believing more strongly that mental health treatment would help a claim differentially attended PTSD treatment before the examination than after. The effect was not observed for general mental health treatment use. CONCLUSION: The association between Veterans' use of PTSD treatment and their service-connection examination status was moderated by beliefs that receiving treatment affects the service-connection decision. This suggests that factors reported to motivate seeking service-connection-finances, validation of Veterans' experiences, and the involvement of significant others-might also help motivate Veterans' use of effective PTSD treatments. However, the results reflect correlations that could be explained in other ways, and service-connection was one of many factors impacting PTSD treatment engagement.

A Conceptual Model for the Evaluation of Surgical Missions.

BACKGROUND: Medical missions to low and middle-income countries are increasingly frequent, with an estimated 6,000 trips sponsored by U.S. organizations accounting for approximately 200,000 surgical cases and $250 million in costs annually. However, these missions have received little critical evaluation. This paper describes the research program Operation Walk (Op-Walk) Boston, and proposes an evaluation model for similar surgical missions. METHODS: We propose an evaluation model, borrowing from the work of Donabedian and enriched by evidence from our research program. The model calls for evaluation of the salient contextual factors (culture and beliefs), system management (structure, process, and outcomes), and sustainability of the program's interventions. We used these domains to present findings from the quantitative and qualitative research work of Op-Walk Boston. RESULTS: Op-Walk's qualitative research findings demonstrated that cultural factors are important determinants of patients' perceptions of arthritis etiology, physical activity patterns, and treatment preferences. Quantitative assessments documented that Dominican patients had worse lower-extremity functional status (mean Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] function score of 33.6) and pain preoperatively than patients undergoing total hip or knee replacement in the U.S. (WOMAC function score of 43.3 to 54), yet they achieved excellent outcomes (50-point improvement), comparable to those of their U.S. counterparts. Assessments of the quality and sustainability of the Op-Walk program showed that the quality of care provided by Op-Walk Boston meets Blue Cross Blue Shield Centers of Excellence (Blue Distinction) criteria, and that sustainable changes were transferred to the host hospital. CONCLUSIONS: Our proposed model offers a method for formal assessment of medical missions that addresses the call for evidence of their merit. We suggest that surgical missions adopt quantitative and qualitative strategies to document their impact, identify areas of improvement, and justify program continuation, growth, and support.

Predictors of Patient-Reported Outcomes of Total Joint Arthroplasty in a Developing Country.

BACKGROUND: In response to the growing burden of joint disease, developing countries are starting to create their own total joint arthroplasty (TJA) programs. To date, there has been limited research on predictors of TJA outcomes in a developing country. This investigation uses patient-reported outcome measures collected by a medical mission to assess predictors of TJA outcomes in the Dominican Republic. METHODS: Baseline and postoperative information from 156 of the mission's recipients of hip and knee TJA was used. Demographics were abstracted from clinical notes, and self-reported pain and functional status were assessed using Western Ontario and McMaster University Osteoarthritis Index and Short-Form 36 measures. Bivariate analysis identified variables to include in multivariable regression models of factors associated with function and pain outcomes and improvement in these domains 1 or 2 years postoperatively. RESULTS: The cohort had a mean age of 61.3 years, 82% were female, 79% had total knee arthroplasty, and 42% of the procedures were bilateral. In multivariate analyses, at P < .05, male sex, better preoperative function, and use of bilateral procedure were associated with better functional outcome. Male sex and worse preoperative pain were associated with better pain outcome. Worse preoperative pain and function, as well as bilateral surgery were associated with greater improvement in function. Additionally, a greater number of bothersome joints was associated with greater pain reduction. CONCLUSION: Our findings of better follow-up pain scores among patients with worse pain preoperatively and better functional improvement among those undergoing bilateral replacements contrast with study results from developed countries. The explanations for these observations merit further study.

The Evolution of Implant Design Decreases the Incidence of Lateral Release in Primary Total Knee Arthroplasty.

BACKGROUND: Appropriate balancing of the patellofemoral joint (PFJ) using a lateral release can help to prevent patellar instability in total knee arthroplasty (TKA). Contemporary total knee implant designs are characterized by enhanced trochlear geometry more similar to native knee anatomy to minimize instability and reduce utilization of a lateral release. METHODS: We retrospectively reviewed consecutive TKA cases from a single senior surgeon's practice with 3 successive total knee designs: the Press-Fit Condylar (PFC), the Sigma, and the ATTUNE (DePuy, Warsaw, IN). We evaluated the use of lateral release with each implant type to determine if design changes have improved patellar stability, reducing the need for lateral release. We used multivariate analysis to determine the association between implant type and lateral release, adjusting for age, sex, preoperative alignment, and bearing type. RESULTS: We evaluated 1991 records of primary TKAs performed from 1980-2015. As compared with the ATTUNE, the adjusted odds of lateral release were greater for patients receiving PFC implants (Odds ratio [OR] 6.35, 95% confidence interval [CI] 3.85,10.49) and Sigma implants (OR 2.02, 95% CI 1.26, 3.23). In addition, fixed bearing implants were associated with greater adjusted odds of lateral release (OR 1.80, 95% CI 1.24, 2.62). CONCLUSION: We found that older knee implants were associated with higher use of lateral release, with successive designs the need for lateral release to balance the PFJ decreased. Continued design improvements to match the native knee anatomy may further improve the stability of the PFJ in future designs.

Postoperative Pain Management Among Dominican and American Health-Care Providers: A Qualitative Analysis.

BACKGROUND: U.S. practitioners have prescribed opioid analgesics increasingly in recent years, contributing to what has been declared an opioid epidemic by the U.S. Centers for Disease Control and Prevention (CDC). Opioids are used frequently in the preoperative and postoperative periods for patients undergoing total joint replacement in developed countries, but cross-cultural comparisons of this practice are limited. An international medical mission such as Operation Walk Boston, which provides total joint replacement to financially vulnerable patients in the Dominican Republic, offers a unique opportunity to compare postoperative pain management approaches in a developed nation and a developing nation. METHODS: We interviewed American and Dominican surgeons and nurses (n = 22) during Operation Walk Boston 2015. We used a moderator's guide with open-ended questions to inquire about postoperative pain management and factors influencing prescribing practices. Interviews were recorded and transcripts were analyzed using content analysis. RESULTS: Providers highlighted differences in the patient-provider relationship, pain medication prescribing variability, and access to medications. Dominican surgeons emphasized adherence to standardized pain protocols and employed a paternalistic model of care, and American surgeons reported prescribing variability and described shared decision-making with patients. Dominican providers described limited availability of potent opioid preparations in the Dominican Republic, in contrast to American providers, who discussed opioid accessibility in the United States. CONCLUSIONS: Our findings suggest that cross-cultural comparisons provide insight into how opioid prescribing practices, approaches to the patient-provider relationship, and medication access inform distinct pain management strategies in American and Dominican surgical settings. Integrating lessons from cross-cultural pain management studies may yield more effective pain management strategies for surgical procedures performed in the United States and abroad.