What Is the Efficacy of a Nonoperative Program Including a Specific Stretching Protocol for Flexor Hallucis Longus Tendonitis?

BACKGROUND: Diagnosis and treatment of tendonitis/entrapment of the flexor hallucis longus (FHL) has been sporadically described in the evidence, primarily in the context of dancers and other athletes. Although various nonspecific nonoperative treatments have been described, it is not clear how often they achieve a satisfactory amount of symptom improvement. QUESTIONS/PURPOSES: The present study was designed to address the following questions regarding the nonoperative treatment of FHL tendonitis: (1) In a population of patients where the default management option for FHL tendonitis is a comprehensive nonsurgical approach, what proportion of patients thus treated opted not to have surgery? (2) What factors were associated with a patient's decision to undergo surgery after a period of nonsurgical management? METHODS: The 656 patients included were all those diagnosed with FHL tendonitis who were initially treated nonoperatively in the foot and ankle division between January 2009 and December 2018. Demographics, comorbidities, examination findings, imaging results, pain scores, treatment instituted, and final outcome were obtained from the electronic medical record. The primary outcome was the decision to have surgery due to unsatisfactory symptom improvement. We compared patients who opted for surgery with those who did not after nonoperative treatment with univariable and multivariable statistics using demographics, comorbidities, and clinical findings as potential risk factors, with p < 0.05. RESULTS: Forty-four percent (180 of 409) of patients decided to forgo surgery after the institution of a specific FHL stretching program. Surgery was more likely in patients with clinical hallux rigidus (OR 2.4 [95% CI 1.16 to 4.97]; p = 0.02) or posteromedial ankle pain (OR 1.78 [95% CI 1.12 to 2.83]; p = 0.01) and less likely in those who completed an FHL stretching program (OR 0.15 [95% CI 0.08 to 0.27]; p < 0.001). CONCLUSION: FHL tendonitis is more common than the previous evidence suggests and frequently occurs in nonathletes. Once it was diagnosed by detection of tenderness anywhere along the tendon, most frequently at the fibroosseous tunnel, nonoperative treatment focused on specific FHL stretching and immobilization in more severe cases reduced the symptoms to the extent that 44% of patients decided that surgery was unnecessary. The key to its diagnosis is awareness that this injury is possible because most patients treated in this study had been previously seen by orthopaedic providers who had not appreciated the presence of the condition, leading to a delay in diagnosis and treatment of more than a year in many patients. LEVEL OF EVIDENCE: Level III, therapeutic study.

International variation in dialysis discontinuation in patients with advanced kidney disease.

BACKGROUND: Decisions about dialysis for advanced kidney disease are often strongly shaped by sociocultural and system-level factors rather than the priorities and values of individual patients. We examined international variation in the uptake of conservative approaches to the care of patients with advanced kidney disease, in particular discontinuation of dialysis. METHODS: We employed an observational cohort study design using data collected from patients maintained on long-term hemodialysis between 1996 and 2015 in facilities across 12 developed countries participating in the Dialysis Outcomes and Practice Patterns Study (DOPPS). The main outcome was discontinuation of dialysis therapy. We analyzed the association between several patient characteristics and time to dialysis discontinuation by country and phase of study entry. RESULTS: A total of 259 343 DOPPS patients contributed data to the study, of whom 48 519 (18.7%) died during the study period. Of the decedents, 5808 (12.0%) discontinued dialysis before death. Rates of discontinuation were higher within the first few months after initiation of dialysis, among older adults, among those with a greater number of comorbidities and among those living in an institution. After adjustment for age, sex, dialysis duration, diabetes and dialysis era, rates of discontinuation were highest in Canada, the United States and Australia/New Zealand (33.8, 31.4 and 21.5 per 1000/yr, respectively) and lowest in Japan and Italy (< 0.1 per 1000/yr). Crude discontinuation rates were highest in dialysis facilities that were more likely to offer comprehensive conservative renal care to older adults. INTERPRETATION: We found persistent international variation in average rates of dialysis discontinuation not explained by differences in patient case-mix. These differences may reflect physician-, facility- and society-level differences in clinical practice. There may be opportunities for international cross-collaboration to improve support for patients with end-stage renal disease who prefer a more conservative approach.

Clubfoot treatment with Ponseti method-parental distress during plaster casting.

BACKGROUND: Clubfoot is one of the most prevalent musculoskeletal congenital defects. Gold standard treatment of idiopathic clubfoot is the conservative Ponseti method, including the reduction of deformity with weekly serial plaster casting and percutaneous Achilles tenotomy. It is well known that parents of children with severe and chronic illnesses are mentally stressed, but in recent studies regarding clubfoot treatment, parents were only asked about their satisfaction with the treatment. Largely unknown is parental distress before and during plaster casting in clubfoot. Therefore, we want to determinate first, how pronounced the parents' worries are before treatment and if they decrease during the therapy. Second, we hypothesized that parents faced with an extreme deformity (high Pirani score), reveal more distress, than parents whose children have a less pronounced deformity (low Pirani score). Therefore, we wanted to investigate whether the Pirani score correlates with the parents' mental resilience in relation to the therapy of the child as a global distress parameter. METHODS: To answer this question, we developed a questionnaire with the following emphases: Physical capacity, mental resilience, motion score, parents score, and child score with point scores 1 (not affected) to 6 (high affected). Subsequently, we interviewed 20 parents whose children were treated with clubfeet and determined the Pirani score of the infants at the beginning (T0) and at the end (TE) of the treatment with plaster casting. RESULTS: High values were obtained in child score (Mean (M) = 3.11), motion score (M = 2.63), and mental resilience (M = 2.25). During treatment, mental resilience improved (p = 0.015) significantly. Spearman correlation coefficient between Pirani score (T0) and mental resilience (T0) is 0.21, so the initial hypothesis had to be rejected. CONCLUSION: The issues of the children are in the focus of parental worries concerning clubfoot treatment, especially the assumed future motion and the assumed ability to play with other children. Particular emphasis should be placed on educating parents about the excellent long-term results in the function of the treated feet especially as this topic shows the greatest parental distress.

Quality of life among caregivers of people with end-stage kidney disease managed with dialysis or comprehensive conservative care.

BACKGROUND: To measure health-related and care-related quality of life among informal caregivers of older people with end-stage kidney disease (ESKD), and to determine the association between caregiver quality of life and care recipient's treatment type. METHODS: A prospective cross-sectional study was conducted. Three renal units in the UK and Australia were included. Informal caregivers of people aged ≥75 years with ESKD managed with dialysis or comprehensive conservative non-dialytic care (estimated glomerular filtration (eGFR) ≤10 mL/min/1.73m2) participated. Health-related quality of life (HRQoL) was assessed using Short-Form six dimensions (SF-6D, 0-1 scale) and care-related quality of life was assessed using the Carer Experience Scale (CES, 0-100 scale). Linear regression assessed associations between care-recipient treatment type, caregiver characteristics and the SF-6D utility index and CES scores. RESULTS: Of 63 caregivers, 49 (78%) were from Australia, 26 (41%) cared for an older person managed with dialysis, and 37 (59%) cared for an older person managed with comprehensive conservative care. Overall, 73% were females, and the median age of the entire cohort was 76 years [IQR 68-81]. When adjusted for caregiver sociodemographic characteristics, caregivers reported significantly worse carer experience (CES score 15.73, 95% CI 5.78 to 25.68) for those managing an older person on dialysis compared with conservative care. However, no significant difference observed for carer HRQoL (SF-6D utility index - 0.08, 95% CI - 0.18 to 0.01) for those managing an older person on dialysis compared with conservative care. CONCLUSIONS: Our data suggest informal caregivers of older people on dialysis have significantly worse care-related quality of life (and therefore greater need for support) than those managed with comprehensive conservative care. It is important to consider the impact on caregivers' quality of life when considering treatment choices for their care recipients.

Evaluación de la percepción preoperatoria de la calidad de vida y satisfacción de la mujer con cáncer de mama mediante el cuestionario BREAST-Q™ / Evaluation of the preoperative perception of quality of life and satisfaction of women with breast cancer using the BREAST-Q™ questionnaire

INTRODUCCIÓN: Cerca del 40% de las mujeres intervenidas por un carcinoma mamario refieren estar insatisfechas con la toma de decisiones y con el resultado cosmético de la cirugía. El objetivo del estudio es demostrar la utilidad del cuestionario prequirúrgico BREAST-Q™ para evaluar la satisfacción y calidad de vida de las mujeres con cáncer de mama en un estado basal previo a la cirugía e identificar perfiles de satisfacción. MÉTODOS: Estudio observacional de una corte prospectiva en mujeres con carcinoma de mama donde se evaluó la calidad de vida antes y después de la intervención propuesta mediante el cuestionario prequirúrgico BREAST-Q™. Se presentan los resultados preliminares del estudio, con el análisis de la fase prequirúrgica. Se calcularon los percentiles para cada dominio del cuestionario y se evaluaron las características físicas basales para su posterior análisis. RESULTADOS: La satisfacción media de las pacientes con sus mamas fue de 58,9 ± 16,9. La media de bienestar psicosocial prequirúrgico fue de 70,5 ± 16,1. A las pacientes que se les propuso una cirugía conservadora presentaron una media de bienestar físico de 80,7 ± 18,5 y a las pacientes que se les propuso una mastectomía con reconstrucción fue de 79,9 ± 17,7. La media de score para el bienestar sexual fue de 63,2 ± 20,7. No se encontraron diferencias estadísticamente significativas entre el grupo de mujeres con score bajo y el grupo con score medio o alto en cuanto a las características clinicoepidemiológicas de las pacientes. CONCLUSIONES: La evaluación preoperatoria de las pacientes con cáncer de mama permite una correcta valoración del impacto de la cirugía sobre la satisfacción y calidad de vida, siendo de utilidad para orientar el proceso informativo acerca de las expectativas de los resultados postoperatorios

INTRODUCTION: Almost 40% of women who undergo breast surgery are dissatisfied with the decision-making process as well as cosmetic results. Our objective was to demonstrate the usefulness of the BREAST-Q™ preoperative questionnaire to evaluate the satisfaction and health-related quality of life in women with diagnosis of breast cancer prior to surgery, as well as identifying satisfaction profiles. METHODS: Prospective cohort observational study in women with breast cancer, evaluating preoperative quality of life using the BREAST-Q™ questionnaire. Percentile measures for each domain and baseline physical characteristics were assessed for posterior analysis. RESULTS: The average score in the breast satisfaction domain was 58.9±16.9. The average score in the preoperative psychosocial well-being domain was 70.5±16.1. Patients who were offered conservative surgery had a mean physical well-being score of 80.7±18.5, and those who were offered mastectomy had an average score of 79.9±17.7. The sexual well-being average score was 63.2±20.7. No statistically significant differences were found between low-score and high-score groups regarding epidemiological and clinical characteristics. CONCLUSIONS: Preoperative evaluation in breast cancer patients provides correct assessment of the effect of surgical treatment on patient satisfaction and quality of life. This information is useful for communicating with patients about their expectations and postoperative results

Treatment Preferences of Patients With Benign Prostatic Hyperplasia Before and After Using a Web-based Decision Aid.

OBJECTIVE: To evaluate treatment preferences of patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH) before and after using a web-based decision aid (DA). PATIENTS AND METHODS: Between July 2016 and January 2017 patients were invited to use a web-based LUTS/BPH DA. Treatment preferences (for lifestyle advices, medication or surgery) before and after DA use and responses on values clarification exercises were extracted from the DA. RESULTS: In total, 126 patients were included in the analysis. Thirty-four percent (43/126) had not received any previous treatment and were eligible for (continuation of) lifestyle advices or to start medication, as initial treatment. The other 66% (83/126) did use medication and were eligible, either for continuing medication or to undergo surgery. Before being exposed to the DA, 67 patients (53%) were undecided and 59 patients (47%) indicated an initial treatment preference. Half of the patients who were initially undecided were able to indicate a preference after DA use (34/67, 51%). Of those with an initial preference, 80% (47/59) confirmed their initial preference after DA use. Five out of 7 values clarification exercises used in the DA were discriminative between final treatment preferences. In 79%, the treatment preferred after DA use matched the received treatment. Overall, healthcare providers were positive about DA feasibility. CONCLUSION: Our findings suggest that a LUTS/BPH DA may help patients to confirm their initial treatment preference and support them in forming a treatment preference if they did not have an initial preference.

Parental preferences in treatment of acute uncomplicated appendicitis comparing surgery to conservative management with antibiotics and their views on research participation.

Studies show that conservative management in acute uncomplicated appendicitis (AUA) is an alternative to surgery. This study aims to determine factors affecting parental preference in management of AUA and their decision for research participation. We conducted surveys on parents whose children were admitted with suspicion of appendicitis but later confirmed not to have appendicitis. Information on appendicectomy versus conservative treatment with antibiotics was provided using a fixed script and standard information leaflet. Questionnaires covered factors influencing decisions, opinions regarding research, treatment preference and demographic data. We excluded parents not fluent in English. Of 113 respondents, 71(62.8%) chose antibiotics, 39(34.5%) chose appendicectomy, and 3(2.7%) had no preference. Reasons given for choosing antibiotics were fear of surgical risks and preferring less invasive treatment. Those choosing appendicectomy expressed preference for definitive treatment and fear of recurrence. Majority were against randomisation (n = 89, 78.8%) and blinding (n = 90, 79.7%). Over half found difficulty involving their child in research (n = 65, 57.5%). Most thought that research is important (66.4%) and beneficial to others (59.3%). Parents who perceived their child as healthy found research riskier (p = 0.039). Educated parents were more likely to find research beneficial to others (p = 0.012) but less accepting of randomisation (p = 0.001).Conclusion: More parents appear to prefer conservative treatment for acute uncomplicated appendicitis. Researchers must consider parental concerns regarding randomisation and blinding.What is Known:• Conservative management of acute uncomplicated appendicitis in paediatric patients is safe and effective, sparing the child the need for an operation; however, neither conservative nor surgical management is proven to be superior.• Randomised controlled trials provide the highest level of evidence, but it is challenging to recruit paediatric patients as participants in such clinical trials.What is New:• More parents prefer conservative management of uncomplicated appendicitis over surgical management for their children due to fear of surgical risks and complications• Randomisation in trial design is significantly associated with a parent's decision to reject their child's participation in a clinical trial.

An Analysis of the Decision-Making Process After "Decision not to Operate" in Acutely Unwell, High-Risk General Surgery Patients.

OBJECTIVES: The purpose of this study was to analyze the decision-making process in emergency general surgery in an attempt to ascertain whether surgeons make the correct decision when decisions not to operate in high-risk acutely unwell surgical patients are taken. BACKGROUND: A decision not to operate is sometimes associated with a certain degree of uncertainty as to the accuracy of the decision. Difficulty lies with the fact that the decisions are made on assumptions, and the tools available are not fool proof. METHODS: We retrospectively evaluated "decisions not to operate" over a period of 32 months from April 2013 to August 2015 in a district general hospital in United Kingdom and compared with consecutive similar number of patients who had an operation as recorded in the National Emergency Laparotomy Audit (NELA) database (from January 2014 to August 2015). We looked at the demographics, American Society of Anesthesiologists grade, Portsmouth-Physiological and Operative Severity Score for enumeration of Mortality and Morbidity (P-POSSUM) score, functional status, and 30-day mortality. RESULTS: Two groups (operated [n = 43] and conservative [n = 42]) had similar characteristics. Patients for conservative management had a higher P-POSSUM score (P < .001) and a poorer functional status (P < .001) at the time of decision-making compared to those who had surgery. Mortality at 30 days was significantly higher for patients decided for conservative management when compared with those who had surgery (76.2% and 18.6%, respectively). CONCLUSIONS: Elderly patients with poorer functional status and predicted risks more often drive multidisciplinary discussions on whether to operate. Within the limitations of not knowing the outcome otherwise, it appears surgeons take a reasonable approach when deciding not to operate.

Evaluation of the preoperative perception of quality of life and satisfaction of women with breast cancer using the BREAST-Q™ questionnaire. / Evaluación de la percepción preoperatoria de la calidad de vida y satisfacción de la mujer con cáncer de mama mediante el cuestionario BREAST-Q™.

INTRODUCTION: Almost 40% of women who undergo breast surgery are dissatisfied with the decision-making process as well as cosmetic results. Our objective was to demonstrate the usefulness of the BREAST-Q™ preoperative questionnaire to evaluate the satisfaction and health-related quality of life in women with diagnosis of breast cancer prior to surgery, as well as identifying satisfaction profiles. METHODS: Prospective cohort observational study in women with breast cancer, evaluating preoperative quality of life using the BREAST-Q™ questionnaire. Percentile measures for each domain and baseline physical characteristics were assessed for posterior analysis. RESULTS: The average score in the breast satisfaction domain was 58.9±16.9. The average score in the preoperative psychosocial well-being domain was 70.5±16.1. Patients who were offered conservative surgery had a mean physical well-being score of 80.7±18.5, and those who were offered mastectomy had an average score of 79.9±17.7. The sexual well-being average score was 63.2±20.7. No statistically significant differences were found between low-score and high-score groups regarding epidemiological and clinical characteristics CONCLUSIONS: Preoperative evaluation in breast cancer patients provides correct assessment of the effect of surgical treatment on patient satisfaction and quality of life. This information is useful for communicating with patients about their expectations and postoperative results.

Analysis of Factors Affecting Quality of Life in Patients Treated for Maxillofacial Fractures.

Maxillofacial fractures (MFF) belong to the major modern medicine and public health concerns. The recovery from MFF is associated with a number of social problems. The patient's mood may be affected by the change in self-image and lack of satisfaction with life, in many cases leading to a deepening of mental health disorders, resulting in alcoholism, loss of job or conflicts in the area of family life. The aim of this study was to evaluate the quality of life of patients with MFF, with respect to demographic and medical variables. The mean age of the 227 patients was 36 years. The mandible was the most frequent MFF location (52.9%), followed by the zygomatic bone (30.8%) then the maxilla (16.3%). Bone fracture displacement occurred in 79.3% of patients. A comminuted fracture was found in 71% of patients. The quality of life of patients with MFF was significantly better in all analyzed domains 3 months after the end of hospitalization compared to the initial survey carried out shortly after implementation of the treatment. Among the demographic variables, older age had a statistically significant but weak positive association with the improvement of the quality of life of respondents in General health perception domain.

"I need somebody who knows about feet" a qualitative study investigating the lived experiences of conservative treatment for patients with posterior tibial tendon dysfunction.

BACKGROUND: Posterior tibial tendon dysfunction is a disabling, chronic, progressive tendon condition that detrimentally affects foot, ankle and lower limb function. Research suggests that posterior tibial tendon dysfunction is poorly recognised and difficult to treat. When posterior tibial tendon dysfunction is diagnosed, the clinician is faced with a weak evidence base and guidelines for the common conservative treatments.to guide their management. Moreover, there are no current evidence-based guidelines for the conservative management of posterior tibial tendon dysfunction. Emerging research suggests that posterior tibial tendon dysfunction not only has a physical impact on the patient, but it also has psychosocial impact on quality of life.Conservative treatments for posterior tibial tendon dysfunction are generally undertaken during early management. The most common are foot orthoses, exercises, bracing, lifestyle changes and injections. Quantitative evidence supporting conservative treatments for posterior tibial tendon dysfunction in relation to function, pain and patient reported outcome measures are reported in the literature.There is a paucity of qualitative research investigating the psychosocial impact of the common treatments for posterior tibial tendon dysfunction. Interpretative phenomenology is concerned with lived experience which is involves the detailed exploration of experience which is embedded within the social and temporal contexts of the lifeworld of the person. The aim of study research is to investigate the lived experience of conservative treatments for patients who have posterior tibial tendon dysfunction using Interpretative Phenomenological Analysis. METHODS: Five participants with posterior tibial tendon dysfunction were purposively recruited from a private podiatry practice and semi-structured interviews were conducted to examine their lived experiences of treatment for posterior tibial tendon dysfunction. The data for this study was collected and analysed using Interpretative Phenomenological Analysis. RESULTS: This research identified three superordinate themes which influenced the lived experience of treatment for these patients (i) adverse experience during the patient journey (ii) treatment burden, and (iii) negative self-concept. CONCLUSION: This study highlights some of what is anecdotally known about the lived experience of treatment for patients with posterior tibial tendon dysfunction, but has never been studied in a qualitative, methodological manner. This study addresses the gap in the qualitative literature. It reveals novel aspects of the lived experience throughout the patient journey, the detrimental impact of treatment burden, loss and negative self-concept. This evidence is important because it highlights the need for a greater understanding of the psychological and social factors that can influence the lived experience of treatment for this group of patients.

Perspectives on decision making amongst older people with end-stage renal disease and caregivers in Singapore: A qualitative study.

BACKGROUND: End-stage renal disease (ESRD) is increasing both globally and in Asia. Singapore has the fifth highest incidence of ESRD worldwide, a trend that is predicted to rise. Older patients with ESRD are faced with a choice of haemodialysis, peritoneal dialysis or conservative management, all of which have their risks and benefits. OBJECTIVE: This study seeks to explore perspectives on decision making amongst older (≥70) Singaporean ESRD patients and their caregivers to undergo (or not to undergo) dialysis. DESIGN: Qualitative study design using semi-structured interviews. SETTING AND PARTICIPANTS: Twenty-three participants were recruited from the largest tertiary hospital in Singapore: seven peritoneal dialysis patients, five haemodialysis patients, four patients on conservative management and seven caregivers. RESULTS: While some patients believed that they had made an independent treatment decision, others reported feeling like they had no choice in the matter or that they were strongly persuaded by their doctors and/or family members to undergo dialysis. Patients reported decision-making factors including loss of autonomy in daily life, financial burden (on themselves or on their families), caregiving burden, alternative medicine, symptoms and disease progression. Caregivers also reported concerns about financial and caregiving burden. DISCUSSION AND CONCLUSION: This study has identified several factors that should be considered in the design and implementation of decision aids to help older ESRD patients in Singapore make informed treatment decisions, including patients' and caregivers' decision-making factors as well as the relational dynamics between patients, caregivers and doctors.

Important differences between quality of life and health status in elderly patients suffering from critical limb ischemia.

INTRODUCTION: Critical limb ischemia (CLI) patients are often of advanced age with reduced health status (HS) and quality of life (QoL) at baseline. Physical health is considered as the most affected domain due to reduced mobility and ischemic pain. QoL and HS are often used interchangeably in the current literature. HS refers to objectively perceived physical, psychological, and social functioning and in assessing QoL, change is measured subjectively and can only be determined by the individual since it concerns patients' evaluation of their functioning. It is important to distinguish between QoL and HS, especially in the concept of shared decision-making when the opinion of the patient is key. Goal of this study was to examine and compare QoL and HS in elderly CLI patients in relation to the used therapy, with a special interest in conservatively treated patients. METHODS: Patients suffering from CLI and ≥70 years old were included in a prospective study with a follow-up period of 1 year. Patients were divided into three groups; endovascular revascularization, surgical revascularization, and conservative therapy. The WHOQoL-Bref was used to determine QoL, and the 12-Item Short Form Health Survey was used to evaluate HS at baseline, 5-7 days, 6 weeks, 6 months, and 1 year. RESULTS: Physical QoL of endovascularly and surgically treated patients showed immediate significant improvement during follow-up in contrast to delayed increased physical HS at 6 weeks and 6 months (P<0.001). Conservatively treated patients showed significantly improved physical QoL at 6 and 12 months (P=0.02) in contrast to no significant improvement in physical HS. CONCLUSION: This study demonstrates that QoL and HS are indeed not identical concepts and that differentiating between these two concepts could influence the choice of treatment in elderly CLI patients. Discriminating between QoL and HS is, therefore, of major importance for clinical practice, especially to achieve shared decision-making.

Psychiatric morbidity and different treatment modalities in children with chronic kidney disease.

INTRODUCTION: Chronic kidney disease (CKD) is a potentially life-threatening condition leading to various psychosocial problems associated with different treatment modalities in addition to their medical advantages and disadvantages. The aim of this study was to evaluate the psychiatric morbidity in children with CKD in terms of different treatment modalities in comparison to healthy peers. In addition, parental attitudes and psychiatric symptoms in this group of mothers were examined. POPULATION AND METHODS: A matched cohort study including 66 children with CKD (21 renal transplantation, 27 dialysis, 18 conservative treatment) and 37 healthy age- and sex-matched controls were evaluated. Children filled out the Children's Depression Inventory, the State-Trait Anxiety Inventory, and the Parental Attitude Scale, and the mothers filled out the Symptom Checklist-90-R. The Schedule for Affective Disorders and Schizophrenia for School-Age Children, Present and Lifetime Version was used for psychiatric diagnosis. RESULTS: The overall depression scores in children and the mothers' overall symptom severity index were significantly higher in the CKD group: 40.9% of children in the CKD group were diagnosed with a psychiatric disorder, while the corresponding figure for the control group was 16.2%. The in-group comparison of the CKD group failed to detect any significant difference between the three treatment modalities. CONCLUSION: The results support the findings of research showing that CKD has high psychiatric morbidity. It is important to include psychosocial and psychiatric assessments in the evaluation processes of different treatment modalities in CKD.

Misconceptions and the Acceptance of Evidence-based Nonsurgical Interventions for Knee Osteoarthritis. A Qualitative Study.

BACKGROUND: In contrast to best practice guidelines for knee osteoarthritis (OA), findings from several different healthcare settings have identified that nonsurgical treatments are underused and TKA is overused. Empirical evidence and qualitative observations suggest that patients' willingness to accept nonsurgical interventions for knee OA is low. A qualitative investigation of why patients may feel that such interventions are of little value may be an important step toward increasing their use in the treatment of knee OA QUESTIONS/PURPOSES: This qualitative study was embedded in a larger study investigating patient-related factors (beliefs/attitudes toward knee OA and its treatment) and health-system related factors (access, referral pathways) known to influence patients' decisions to seek medical care. In this paper we focus on the patient-related factors with the aim of exploring why patients may feel that nonsurgical interventions are of little value in the treatment of knee OA. METHODS: A cross-sectional qualitative study was conducted in a single tertiary hospital in Australia. Patients with endstage knee OA on the waiting list for TKA were approached during their preadmission appointment and invited to participate in one-to-one interviews. As prescribed by the qualitative approach, data collection and data analysis were performed in parallel and recruitment continued until the authors agreed that the themes identified would not change through interviews with subsequent participants, at which point, recruitment stopped. Thirty-seven patients were approached and 27 participated. Participants were 48% female; mean age was 67 years. Participants' beliefs about knee OA and its treatment were identified in the interview transcripts. Beliefs were grouped into five belief dimensions: identity beliefs (what knee OA is), causal beliefs (what causes knee OA), consequence beliefs (what the consequences of knee OA are), timeline beliefs (how long knee OA lasts) and treatment beliefs (how knee OA can be controlled). RESULTS: All participants believed that their knee OA was "bone on bone" (identity beliefs) and most (> 14 participants) believed it was caused by "wear and tear" (causal beliefs). Most (> 14 participants) believed that loading the knee could further damage their "vulnerable" joint (consequence beliefs) and all believed that their pain would deteriorate over time (timeline beliefs). Many (>20 participants) believed that physiotherapy and exercise interventions would increase pain and could not replace lost knee cartilage. They preferred experimental and surgical treatments which they believed would replace lost cartilage and cure their knee pain (treatment beliefs). CONCLUSIONS: Common misconceptions about knee OA appear to influence patients' acceptance of nonsurgical, evidence-based treatments such as exercise and weight loss. Once the participants in this study had been "diagnosed" with "bone-on-bone" changes, many disregarded exercise-based interventions which they believed would damage their joint, in favor of alternative and experimental treatments, which they believed would regenerate lost knee cartilage. Future research involving larger, more representative samples are needed to understand how widespread these beliefs are and if/how they influence treatment decisions. In the meantime, clinicians seeking to encourage acceptance of nonsurgical interventions may consider exploring and targeting misconceptions that patients hold about the identity, causes, consequences, timeline, and treatment of knee OA. LEVEL OF EVIDENCE: Level II, prognostic study.

Quality of life, symptoms, and sleep quality of elderly with end-stage renal disease receiving conservative management: a systematic review.

BACKGROUND: Older patients with end-stage renal disease (ESRD) have experienced diminished quality of life and debilitating symptoms. Conservative management may be a potential treatment option. Currently, limited studies have been conducted about the main outcome of conservative management, including quality of life, symptoms and sleep quality. The aim of this systematic review was to examine the quality of life, symptoms and sleep quality of elderly patients with ESRD undergoing conservative management. METHODS: Evidence-based medicine database (JBI and Cochrane) and original literature database (PubMed, Medline, EMbase, Web of Science) were searched up to March 12, 2018. The quality of included papers was evaluated with the Newcastle-Ottawa Scale. RESULTS: Eight studies met the inclusion criteria. The total of 1229 patients were involved with an average age of 60.6 ~ 82 years. Patients choosing conservative management were older and more functionally impaired compared to those opting for dialysis. 55% patients undergoing conservative management had stable or improved quality of life and symptoms in prospective cohort study. However, the results revealed that there were no significant differences in quality of life and symptom between conservative management and renal replacement therapy. Only one study assessed quality of life of older patients using SF-36, with a lower score in physical health subscale of conservative management patients than those of renal replacement therapy. Although more than 40% of the patients had poor sleep quality, no significant difference was found between conservative management and renal replacement therapy. Sleep disorders were associated with fatigue and other symptoms. CONCLUSIONS: Although there is a limited literature, conservative management is likely to improve quality of life and alleviate symptoms of end-stage renal disease patients with considerable clinical implications mainly in elderly patients. Future study should pay more attention to the various treatment outcomes of conservative management, providing abundant evidence.

Quality of life after the initiation of dialysis or maximal conservative management in elderly patients: a longitudinal analysis of the Geriatric assessment in OLder patients starting Dialysis (GOLD) study.

BACKGROUND: Maximal conservative management (MCM) may be an appropriate alternative option for dialysis in some elderly patients with end-stage kidney disease (ESKD). Evidence about the impact of dialysis or MCM on quality of life (QoL) in older patients is sparse. In the GOLD (Geriatric assessment in OLder patients starting Dialysis) Study the trajectory of QoL was assessed in patients starting dialysis or MCM. METHODS: Patients ≥65 years old were included just prior to dialysis initiation or after decision for MCM. Baseline data included demographics, frailty as measured with a geriatric assessment, comorbidity (CIRS-G) and QoL, measured with the EQ-5D-3 L (EQ-5D Index and overall self-rated health). Six months follow-up data included QoL, hospitalizations and mortality. Change of QoL was assed with paired t-tests. Cox-regression was used to assess survival of MCM and dialysis patients. RESULTS: The cohort comprised 192 dialysis and 89 MCM patients. The MCM patients were older (mean age 82 ± 6 vs. 75 ± 7 years, p <  0.01) and mean kidney function was better (eGFR 11.5 ± 4.0 vs. 8.0 ± 2.9 ml/min/1.73m2, p <  0.01). Baseline QoL did not differ significantly between the groups. After six months, EQ-5D Index did not improve significantly in the dialysis group with mean ± standard error (SE) 0.026 ± 0.014 (p = 0.10; not clinically relevant), but a small but clinically relevant decline was seen in the conservative group: 0.047 ± 0.022 (p < 0.01; between group difference p < 0.01). Hospitalization occurred in 50% of dialysis patients vs. 24% of conservative patients (p < 0.01). In patients over 80 years old, no survival benefit could be found for dialysis patients starting dialysis vs. MCM. CONCLUSION: A small decline of QoL was found for conservative patients, while QoL did not change in dialysis patients. However, hospitalization rate was higher in patients starting dialysis. In patients over 80 years, no survival benefit was found.

Perceptions and Response to Conservative Treatment of Low Back Pain in Soldiers During Initial Entry Training: A Convergence Mixed Methods Study.

Low back pain (LBP) is a common condition suffered by military personnel. Psychosocial factors play a role in LBP prognosis and can be addressed with self-management tools. This study's purpose was to (1) describe clinical changes in psychosocial factors of LBP following a self-management intervention and (2) explore the LBP experience of military trainees. Ten participants in Initial Entry Training (IET) were included in this mixed methods study. A self-management intervention of exercises and psychosocial education was provided. Quantitative instruments assessing psychosocial factors were delivered at baseline and 6 weeks. Qualitative data were gathered after treatment and analyzed using a phenomenological approach. Low levels of psychosocial risk factors were reported. Patient satisfaction (COPM-Satisfaction subscale) was the only outcome that achieved statistical significance at 6 weeks (p = 0.037). Three themes emerged from the qualitative results: the influence of the military culture on recovery from LBP, the LBP experience of a trainee, and promoting the self-management of LBP. While this cohort of IET soldiers exhibited low levels of psychosocial risk factors, qualitative reports indicate that LBP has a negative impact on participation in training, academics, and interpersonal relationships. The constraints of military training make seeking care and applying treatment strategies challenging.