Multidisciplinary management of patients with haemophilia with inhibitors undergoing surgery in the United States: perspectives and best practices derived from experienced treatment centres.

Since the 1980s, major surgical interventions in patients with congenital haemophilia with inhibitors have been performed utilizing bypassing agents for haemostatic coverage. While reports have focused on perioperative management and haemostasis, the US currently lacks consensus guidelines for the management of patients with inhibitors during the surgical procedure, and pre- and postoperatively. Many haemophilia treatment centres (HTCs) have experience with surgery in haemophilia patients, including those with inhibitors, with approximately 50% of these HTCs having performed orthopaedic procedures. The aim of this study was to present currently considered best practices for multidisciplinary care of inhibitor patients undergoing surgery in US HTCs. Comprehensive haemophilia care in the US is provided by ~130 federally designated HTCs staffed by multidisciplinary teams of healthcare professionals. Best practices were derived from a meeting of experts from leading HTCs examining the full care spectrum for inhibitor patients ranging from identification of the need for surgery through postoperative rehabilitation. HTCs face challenges in the care of inhibitor patients requiring surgery due to the limited number of surgeons willing to operate on this complex population. US centres of excellence have developed their own best practices around an extended comprehensive care model that includes preoperative planning, perioperative haemostasis and postoperative rehabilitation. Best practices will benefit patients with inhibitors and allow improvement in the overall care of these patients when undergoing surgical procedures. In addition, opportunities for further education and outcomes assessment in the care of this patient population have been identified.

Assessment and management of pain in haemophilia patients.

Haemophilia patients experience acute pain during joint bleeds and chronic pain from haemophilic arthropathy. More than 50% of haemophilia patients have painful joints that cause disability and impair quality of life. Unfortunately, only a few clinical studies have investigated the non-pharmacological or pharmacological treatments for pain or the adverse effects of pain on the health and quality of life of children and adults with haemophilia. There are no detailed algorithms or guidelines for pain management in haemophilia patients, and treatment is largely empirical. Therefore, a standardized approach to the management of pain in haemophilia patients is needed. This approach should include a close relationship between pain specialists and the staffs at haemophilia treatment centres; validated instruments specific to haemophilia for assessing pain, quality of life and disability; and stepwise algorithms/protocols for treatment of chronic vs. acute pain and prophylactic vs early treatment. A pain treatment protocol should include a definition of the problem of pain and best practices for physicians. A call to action is needed to standardize treatment approaches to pain and to develop algorithms/protocols for the management of pain in haemophilia patients. This review will highlight the prevalence and devastating impact of pain in haemophilia patients, currently available treatment options and identify the unmet needs for pain management.

The effect of temperature, storage time and collection method on biomethane potential of source separated household food waste.

The aim of this study was to mimic real conditions for storage and transport and to evaluate how much of the biomethane potential is lost before the organic fraction of municipal solid waste (OFMSW) from households in Sweden reaches the biogas plant. The laboratory biomethane potential (BMP) experiments was carried out with respect to the storage time, collection method (paper or plastic bag) and storage temperature (22°C and 6°C) in order to evaluate the effect of these factors on the biomethane potential. A recipe representative for OFMSW from households in Sweden was designed with the help of literature and modification of recipes from technical reports and scientific literature. Laboratory experiments showed that the difference in the BMP of OFMSW stored in plastic- compared to paper bags were obvious at 22°C with a lower biomethane potential for paper bags, but there was no difference at 6°C. Provided that the loss of organic matter during pre-treatment is equivalent for both paper and plastic bags it is possible to get more biomethane from OFMSW collected in plastic bags during the warmest part of the year, since they have a more preservative effect on OFMSW than paper bags. This could be explained by the plastic bags being denser than paper and therefore maintain the volatile organic compounds inside the bag and promote a pre-hydrolysis of the material rather than aerobic degradation.

Arthroplasty in the goat hip.

The goat is a reliable and practical animal model for study of the hip. The authors describe a safe and effective operative approach to the goat hip.

Clinical outcome after fusion of the thoracic or lumbar spine in the adult patient.

This article highlights those disease processes for which fusion is used most frequently in the adult. Although the focus is on clinical outcome after fusion, the indications and natural history of the process itself are also briefly discussed to provide a comparative basis on which outcomes may be judged.

Outpatient cardiac rehabilitation in elderly patients.

Exercise as part of cardiac rehabilitation plays a role in minimizing disability associated with myocardial infarction and coronary artery bypass surgery. The beneficial effects have been documented primarily among middle-aged participants. The study of those aged 65 years or greater has received less attention. The purpose of this review article is to summarize available data regarding exercise training in elderly patients with heart disease and review issues and considerations for their participation, together providing a basis for inclusion of more elderly in cardiac rehabilitation. Both male and female elderly patients with heart disease can benefit from exercise through significant improvements in functional capacity and reduced myocardial work. Changes are similar in magnitude to those observed among younger participants. Because elders are the fastest growing U.S. population segment and have a twofold to threefold higher incidence of acute myocardial infarction than younger individuals, decreasing disability by including more elderly in cardiac rehabilitation has important public health implications.

When is total hip arthroplasty a failure? The patients' perspective.

Total hip arthroplasty (THA) patients (186 primary, 92 revision) were surveyed regarding their satisfaction, their expectations regarding longevity, of the hip implant, and their perspective on the potential or actual need for revision surgery. The vast majority of patients were glad they had the original THA, would do it again if faced with a similar choice, and would recommend it to others. One-third of patients believed their current implants would last the rest of their life. The most common responses to either potential or actual failure were happiness it lasted as long as it did, accepting it as "one of those things," and disappointment. No primary THA patients and only 7% of revision of THA patients indicated that they would consider the primary THA a failure when revision surgery was indicated.

Social support and the elderly client.

The elderly have a higher risk of experiencing less social support because of role losses and changes associated with aging and chronic disease processes, and there is pressure from third-party payors to reduce the length of home healthcare services. Few studies have examined patients' instrumental social support after discharge from home healthcare. Therefore, this descriptive study examined instrumental social support of discharged home healthcare clients (N = 57) who were older than 65 years old, using a telephone interview and retrospective record review. The purposes were to investigate (1) source and number of sources of received support based on age, gender, marital status, race, and functional ability; (2) whether source of support was associated with physical and mental health outcomes; (3) whether clients' perception of need for more support was associated with physical and mental health outcomes. The results indicated that the number of sources of social support was associated with clients' gender, marital status; and functional status; trends toward improvements in mental and physical health outcomes were associated with support provided by friends and neighbors.

Analysis of a home health agency's productivity system.

Productivity is an important issue in home care. Employee perceptions of an equitable system are crucial and have been linked to job satisfaction, motivation, and production. Ten staff nurses, and all supervisors and program directors were interviewed to elicit perceptions of the productivity system. Staff nurses' time sheets for seven months were evaluated retrospectively for visit length, number of visits per day, payer source, mileage per day, and travel time per day. Mean time in minutes spent in the patient's home on intravenous visits (n = 58 visits) was approximately twice as long as that of home care visit (n = 11,573 visits). Mean length of hospice visits (n = 368 visits) was 25 to 29 minutes longer than that of mean home care visits. The proportion of Medicare reimbursement was negatively correlated with productivity bonus point achievement (when two high and two low bonus point outliers were removed). Recommended changes were based on both qualitative analysis of employee perceptions of the productivity system and quantitative analysis of time sheets.

Use of the stages of change in exercise adherence model among older adults with a cardiac diagnosis.

PURPOSE: Researchers have recommended use of the Stages of Change in Exercise Adherence (STAGES), a process-oriented model, to better understand exercise adherence behavior. This study aimed to further understand the process by evaluating the predictors of exercise adherence and the validity of the STAGES model among older adults (N = 349) with a cardiac diagnosis after discharge from a cardiac rehabilitation inpatient program. METHODS: Recently discharged inpatient participants, aged 65 years or older and ambulatory, responded to a computer-assisted telephone interview regarding their exercise behaviors and attitudes toward exercise (mean response time = 32.3 minutes). Between 55 and 80 participants in each of five stages of exercise adherence were interviewed. Demographic profiles and other information were obtained from a chart review of cardiac rehabilitation inpatient records. RESULTS: Perceived self-efficacy, perceived benefits of exercise, interpersonal support for exercise, and perceived barriers to exercise were significant predictors of exercise adherence using direct entry discriminant analysis. These predictors accounted for 50% of the variance in stage of exercise adherence. The theoretical ordering of the STAGES model was supported (P < .0001). Exercise time significantly increased with each subsequent stage of exercise adherence from the precontemplation stage to the maintenance stage. CONCLUSIONS: This study evaluated the validity of the STAGES model in a sample of older cardiac rehabilitation participants. The STAGES model can be applied to the study of exercise behavior among this group of older adults.

Omnifit cementless total hip arthroplasty. A 10-year average followup.

Seventy-six hips in 67 patients were evaluated an average of 119 months (range, 61-150 months) after total hip arthroplasty with porous coated Omnifit femoral and acetabular components. The patients were young (average age, 45 years), and most were male (67%). Two stems and one cup were revised for aseptic loosening, for aseptic revision rates of 2.6% on the femoral side and 1.3% on the acetabular side. Thigh pain was present in three cases, one of which was activity limiting. Twenty-five (35.7%) hips had evidence of osteolysis confined to proximal Gruen Zone 1 or 7 or to the acetabulum (22 proximal femoral, three both). There were no cases of intramedullary osteolysis in surviving stems. Thirteen (17.1%) hips have undergone reoperation for bone grafting of progressive proximal osteolysis without component revision, at an average 93 months after the total hip arthroplasty. At an average 40 months after reoperation, all stems remain well fixed, and there has been no recurrence of osteolysis of grafted femoral lesions. These results suggest that a circumferentially proximally porous coated femoral component in cementless total hip arthroplasty can provide stable fixation for as long as 12 years after implantation and caseal the canal from distal osteolysis. Serious concerns remain about the incidence of proximal femoral osteolysis.

Nonunion of extended trochanteric osteotomies in impaction grafting femoral revisions.

Extended trochanteric osteotomies have been recommended to facilitate femoral component removal, femoral cement removal, and acetabular exposure in cases of difficult revision hip arthroplasty. Complications due to the osteotomy have been rare and no nonunions have been reported when this osteotomy has been used in conjunction with extensively porous-coated implants. It has been suggested that the osteotomy should also work well with impaction grafting revisions. This is a report of two cases of nonunion of extended trochanteric osteotomies in which the impaction grafting technique was used.