Uptake of intermittent preventive treatment of malaria in pregnancy and risk factors for maternal anaemia and low birthweight among HIV-negative mothers in Dschang, West region of Cameroon: a cross sectional study.

BACKGROUND: Approximately 32 million pregnant women are at risk of malaria with up to 10,000 maternal deaths and 200,000 neonates at risk annually. Intermittent Preventive Treatment (IPT) with sulfadoxine-pyrimethamine (SP) is recommended by the World Health Organization (WHO) to reduce disease in pregnancy and adverse maternal and newborn outcomes. At least three doses of SP should be taken by pregnant women during antenatal consultation (ANC) beginning from the thirteenth week of pregnancy till parturition. The aim of this study was to assess uptake of IPT during pregnancy and risk factors for maternal anaemia and infant birth weight in Dschang, West region of Cameroon. METHODS: A total of 380 consenting pregnant women at delivery were recruited in a cross- sectional prospective survey between January to December 2021. Data on ANC attendance, total dose of IPT and history of malaria were abstracted from hospital ANC records while socio-demographic characteristics, bed net use and obstetrics history of each participant were also recorded through an interview. Further, blood samples were collected from the intervillous space for assessment of maternal anaemia and microscopic parasitology. Nested PCR based on amplification of the Plasmodium 18S sRNA was carried out to detect submicroscopic infection. IPTp coverage was calculated per WHO recommendation and the prevalence of anaemia and low birth weight were estimated as proportions in the total sample of pregnant women and live births, respectively. Crude and adjusted odds ratios and their 95% confidence intervals were used to estimate associations between pregnancy outcomes considered and risk factors in specific and general models. A p < 0.05 was considered significant. The R software (V4.1.4) was used for all analyses. RESULTS: A majority of pregnant women was aged between 24 and 34 years old (59.2%) and had secondary education (58.8%). Uptake of ≥ 3 IPTp was 64.99% with 77.20% of all who received at least one IPTp doses taking a mix of SP and DP or DP alone in successive ANC contacts. Those with four or more ANC contacts (73.42%) were more likely to have received at least one IPTp. Furthermore, 13.9% of live births had low birthweights (BW < 2500 g) and one in four parturient women with moderate anaemia by WHO criteria. Microscopy (blood smear examination) and PCR-based diagnosis revealed between 0% and 1.57% of parasite-infected placental samples, respectively. Reported malaria in pregnancy predicted maternal anaemia at birth but not birth weight. Only gestational age (< 37 weeks) and bed net use (< 5 months) significantly predicted infant birth weight at delivery. CONCLUSION: The uptake of WHO recommended IPT doses during pregnancy was moderately high. Reported malaria in pregnancy, poor bed net coverage, gestational age less than 37 weeks adversely affect maternal haemoglobin levels at birth and infant birth weight. Asymptomatic and submicroscopic placental parasite infections was found at low prevalence. Together these results highlight the importance of maintaining aggressive measures to prevent malaria in pregnancy and protect the health of mother and baby.

Autogenous and efficient acceleration of energetic ions upstream of Earth's bow shock.

Earth and its magnetosphere are immersed in the supersonic flow of the solar-wind plasma that fills interplanetary space. As the solar wind slows and deflects to flow around Earth, or any other obstacle, a 'bow shock' forms within the flow. Under almost all solar-wind conditions, planetary bow shocks such as Earth's are collisionless, supercritical shocks, meaning that they reflect and accelerate a fraction of the incident solar-wind ions as an energy dissipation mechanism1,2, which results in the formation of a region called the ion foreshock3. In the foreshock, large-scale, transient phenomena can develop, such as 'hot flow anomalies'4-9, which are concentrations of shock-reflected, suprathermal ions that are channelled and accumulated along certain structures in the upstream magnetic field. Hot flow anomalies evolve explosively, often resulting in the formation of new shocks along their upstream edges5,10, and potentially contribute to particle acceleration11-13, but there have hitherto been no observations to constrain this acceleration or to confirm the underlying mechanism. Here we report observations of a hot flow anomaly accelerating solar-wind ions from roughly 1-10 kiloelectronvolts up to almost 1,000 kiloelectronvolts. The acceleration mechanism depends on the mass and charge state of the ions and is consistent with first-order Fermi acceleration14,15. The acceleration that we observe results from only the interaction of Earth's bow shock with the solar wind, but produces a much, much larger number of energetic particles compared to what would typically be produced in the foreshock from acceleration at the bow shock. Such autogenous and efficient acceleration at quasi-parallel bow shocks (the normal direction of which are within about 45 degrees of the interplanetary magnetic field direction) provides a potential solution to Fermi's 'injection problem', which requires an as-yet-unexplained seed population of energetic particles, and implies that foreshock transients may be important in the generation of cosmic rays at astrophysical shocks throughout the cosmos.

Incidence and Predictors of Subsidence Using Modular, Tapered, Fluted Titanium Femoral Stems in Aseptic Revision Total Hip Arthroplasty.

BACKGROUND: Tapered, fluted titanium (TFT) femoral stems have become the gold standard in revision total hip arthroplasty (rTHA). However, there is a paucity of data on TFT stem subsidence rates following aseptic rTHA. Subsidence can lead to instability, mechanical failure, leg-length discrepancy, and may require revision surgery. This study evaluated the incidences and predictors of TFT subsidence in aseptic rTHA. METHODS: A total of 102 TFT femoral stems of 4 designs were retrospectively reviewed. Stem subsidence was measured on digital radiographs taken immediately after surgery and at standard clinical follow-up. Patient characteristics, risk factors for subsidence, revision etiologies, and implant characteristics were recorded. Patient-reported outcome measures were also evaluated for a subset of cases. RESULTS: Overall, 12% of stems subsided >1 cm, and subsidence was minimal (<3 mm) in ≥64% of cases. From immediate postoperative to 1-month radiographic follow-up, 79% of stems subsided a mean of 2.9 mm (range, 0.1 to 12 mm). Beyond 1 month, subsidence was minimal for ≥77% of cases. In multivariate analyses, women and less femoral implant canal fill were associated with greater subsidence (P ≤ .034). The TFT stem design was not associated with early subsidence (P = .816). There were no modular junction fractures. There were 2 fractures and 2 subsidence-related revisions for aseptic loosening that occurred postoperatively. CONCLUSIONS: The amount of subsidence in TFT stems was low and was detectable in the early (less than 1 year) postoperative period. Maximizing TFT stem fill within the femoral canal appears to reduce the risk of subsidence without increasing femoral fracture rates and should be the goal with implantation of these devices. LEVEL OF EVIDENCE: IV-Case Series, No Control Group.

Survivorship and Patient Outcomes of Conforming Bearings in Modern Primary Total Knee Arthroplasty: Mean 3.5 Year Follow-Up.

BACKGROUND: The use of conforming and congruent bearings in total knee arthroplasty (TKA) have rapidly increased due to the benefits of increased stability and the potential for replicating normal knee kinematics. However, limited data exist for these newly available bearings. This study evaluated revision-free survivorship and patient-reported outcome measures (PROMs) of a large granular database of primary TKAs using a single conforming bearing design. METHODS: A total of 1,306 consecutive primary TKAs performed using a single conforming bearing design (85% cemented and 15% cementless) were retrospectively reviewed. Kaplan-Meier survivorship estimates were calculated based on the latest clinical follow-up. The PROMs and minimal clinically important differences were evaluated. A total of 93% of cases achieved minimum 1-year clinical follow-up (mean 3.5 years; range, 1 to 7), with a subset of 261 cases that achieved minimum 5-year follow-up (mean 5.8 years; range, 5 to 7). RESULTS: All-cause and aseptic Kaplan-Meier survivorship estimates were 97.6 (95% CI [confidence interval], 97 to 99) and 98.1% (95% CI, 97 to 99) at 7.0 years. Revision-free survivorship did not differ by cemented or cementless fixation (98 versus 97%, P = .163). All PROM scores significantly improved from preoperative baseline (P < .001), and ≥ 86% of patients achieved minimal clinically important differences for Knee Society pain and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement total scores. A total of 89% of cases reported their knees to 'sometimes or always' feel normal. For cases with minimum 5-year PROMs, 93% were 'very satisfied' or 'satisfied.' CONCLUSIONS: Conforming-bearing TKA demonstrated excellent survivorship up to 7.0 years. In addition, PROMs were comparable to other designs reported in the literature. While mid-term (mean 3.5-year) results are promising, long-term data are warranted on survivorship due to potential polyethylene wear in conforming bearings with more surface area in contact with articulating surfaces. LEVEL OF EVIDENCE: IV.

Medicaid Patients Travel Disproportionately Farther for Revision Total Joint Arthroplasty.

BACKGROUND: Access to high-quality care for revision total joint arthroplasty (rTJA) is poorly understood but may vary based on insurance type. This study investigated distance traveled for hip and knee rTJA based on insurance type. METHODS: A total of 317 revision hips and 431 revision knees performed between 2010 and 2020 were retrospectively reviewed. Cluster sampling was used to select primary hips and knees for comparison. Median driving distance was compared based upon procedure and insurance type. RESULTS: Revision hip and knee patients traveled 18.2 and 11.0 miles farther for surgery compared to primary hip and knee patients (P ≤ .001). For hip rTJA, Medicaid patients traveled farther than Medicare patients followed by commercially insured patients with median distances traveled of 98.4, 67.2, and 35.6 miles, respectively (P = .016). Primary hip patients traveled the same distance regardless of insurance type (P = .397). For knee rTJA, Medicaid patients traveled twice as far as Medicare and commercially insured patients (medians of 85.0, 43.5, and 42.2 miles respectively, P ≤ .046). Primary knee patients showed a similar pattern (P = .264). Age and ASA-PS classification did not indicate greater comorbidity in Medicaid patients. CONCLUSION: Insurance type may influence rTJA referrals, with disproportionate referral of Medicaid and Medicare patients to nonlocal care centers. In addition to patient burden, these patterns potentially present a financial burden to facilities accepting referrals. Strategies to improve equitable access to rTJA, while maintaining the highest and most economical standards of care for patients, providers, and hospitals, are encouraged.

Durability of Primary Total Hip Arthroplasty With Cementless Stems Without a Collar in Elderly Patients Age 75 Years and Over.

BACKGROUND: Cementless femoral fixation in total hip arthroplasty (THA) has increased in prevalence worldwide. However, cementless fixation in elderly patients is controversial due to the risks of periprosthetic fracture and aseptic loosening. This study evaluated outcomes in patients undergoing primary THA utilizing a cementless stem without a collar, comparing those less than 75 years to those older than 75 years. METHODS: Between 2011 and 2021, there were 2,605 cementless THAs performed by 4 surgeons utilizing a highly porous metal fixation surface without a collar and consistent clinical protocols. There were 469 patients who had an age ≥ 75 years. Revision rates, intraoperative fractures, and 90-day mortality were compared between cohorts. In the ≥ 75 year age group, there were more women, more American Society of Anesthesiologists physical status classification III or IV, a lower body mass index, and more kidney disease, osteoporosis, and thyroid disease (P ≤ .002). RESULTS: All-cause revision rates trended lower for the ≥75 year age group compared to < 75 year (1.9 versus 3.5%, P = .082) at 20-months of follow-up. Moreover, there was no difference in all-cause femoral component revisions comparing ≥ 75 to < 75 year age groups (1.5 versus 2.2%, P = .375), with only 3 of 10 femoral revisions due to aseptic loosening being in the ≥ 75 year age group. Intraoperative fracture (0.2 versus 0.5%, P = .701) and 90-day mortality (0.2 versus 0.1%, P = .460) did not differ between ≥ 75 and < 75 year age groups. CONCLUSIONS: Older patients had comparable revision rates compared to younger patients using cementless femoral fixation without a collar. Furthermore, there was no difference in 90-day mortality or intraoperative fracture rates. Study findings provide evidence for the safety and durability of cementless THA using collarless femoral stems in elderly patients ≥ 75 years of age. LEVEL OF EVIDENCE: III.

Venetoclax sensitivity in multiple myeloma is associated with B-cell gene expression.

Venetoclax is a highly potent, selective BCL2 inhibitor capable of inducing apoptosis in cells dependent on BCL2 for survival. Most myeloma is MCL1-dependent; however, a subset of myeloma enriched for translocation t(11;14) is codependent on BCL2 and thus sensitive to venetoclax. The biology underlying this heterogeneity remains poorly understood. We show that knockdown of cyclin D1 does not induce resistance to venetoclax, arguing against a direct role for cyclin D1 in venetoclax sensitivity. To identify other factors contributing to venetoclax response, we studied a panel of 31 myeloma cell lines and 25 patient samples tested for venetoclax sensitivity. In cell lines, we corroborated our previous observation that BIM binding to BCL2 correlates with venetoclax response and further showed that knockout of BIM results in decreased venetoclax sensitivity. RNA-sequencing analysis identified expression of B-cell genes as enriched in venetoclax-sensitive myeloma, although no single gene consistently delineated sensitive and resistant cells. However, a panel of cell surface makers correlated well with ex vivo prediction of venetoclax response in 21 patient samples and may serve as a biomarker independent of t(11;14). Assay for transposase-accessible chromatin sequencing of myeloma cell lines also identified an epigenetic program in venetoclax-sensitive cells that was more similar to B cells than that of venetoclax-resistant cells, as well as enrichment for basic leucine zipper domain-binding motifs such as BATF. Together, these data indicate that remnants of B-cell biology are associated with BCL2 dependency and point to novel biomarkers of venetoclax-sensitive myeloma independent of t(11;14).

Final results of a phase 1 study of loncastuximab tesirine in relapsed/refractory B-cell non-Hodgkin lymphoma.

The prognosis for patients with relapsed or refractory (R/R) B-cell non-Hodgkin lymphoma (B-NHL) remains poor, with a need for alternatives to current salvage therapies. Loncastuximab tesirine (ADCT-402) is an antibody-drug conjugate comprising a humanized anti-CD19 monoclonal antibody conjugated to a pyrrolobenzodiazepine dimer toxin. Presented here are final results of a phase 1 dose-escalation and dose-expansion study in patients with R/R B-NHL. Objectives were to determine the maximum tolerated dose (MTD) and recommended dose(s) for expansion and evaluate safety, clinical activity, pharmacokinetics, and immunogenicity of loncastuximab tesirine. Overall, 183 patients received loncastuximab tesirine, with 3 + 3 dose escalation at 15 to 200 µg/kg and dose expansion at 120 and 150 µg/kg. Dose-limiting toxicities (all hematologic) were reported in 4 patients. The MTD was not reached, although cumulative toxicity was higher at 200 µg/kg. Hematologic treatment-emergent adverse events were most common, followed by fatigue, nausea, edema, and liver enzyme abnormalities. Overall response rate (ORR) in evaluable patients was 45.6%, including 26.7% complete responses (CRs). ORRs in patients with diffuse large B-cell lymphoma (DLBCL), mantle cell lymphoma, and follicular lymphoma were 42.3%, 46.7%, and 78.6%, respectively. Median duration of response in all patients was 5.4 months and not reached in patients with DLBCL (doses ≥120 µg/kg) who achieved a CR. Loncastuximab tesirine had good stability in serum, notable antitumor activity, and an acceptable safety profile, warranting continued study in B-NHL. The recommended dose for phase 2 was determined as 150 µg/kg every 3 weeks for 2 doses followed by 75 µg/kg every 3 weeks. This trial was registered at www.clinicaltrials.gov as #NCT02669017.

Plain Language Summary of the iNNOVATE study: ibrutinib plus rituximab is well-tolerated and effective in people with Waldenström's macroglobulinemia.

WHAT IS THIS SUMMARY ABOUT?: This article provides a short summary of 5-year results from the iNNOVATE trial. The original paper was published in the Journal of Clinical Oncology in October 2021. People with Waldenström's macroglobulinemia (WM) were randomly divided into two groups of 75 people each. One group received a combination treatment composed of two drugs, ibrutinib plus rituximab, and the other group took placebo ("sugar pill") plus rituximab. Ibrutinib (also known by the brand name Imbruvica®) is a drug that reduces cancer cells' ability to multiply and survive. Ibrutinib is an FDA-approved drug for the treatment of WM. Rituximab is a drug that helps the immune system find and kill cancer cells. Participants in the trial were treated and their health monitored for up to 5 years (63 months). WHAT WERE THE RESULTS?: During the 5 years of monitoring, more people who took ibrutinib plus rituximab experienced an improvement in their disease and lived longer without their disease getting worse compared to those who took placebo plus rituximab. Side effects from ibrutinib and rituximab were manageable and generally decreased over time. Participants in both study groups reported improvements in quality of life, but those who took ibrutinib plus rituximab reported significantly greater improvement in their quality of life (as measured by FACT-An score) compared to those who took placebo plus rituximab. WHAT DO THE RESULTS MEAN?: These results show that ibrutinib plus rituximab is better than rituximab alone in people with WM and that ibrutinib plus rituximab is safe and effective in the long term. This information confirms the role of ibrutinib plus rituximab as a standard of care for WM. Clinical Trial Registration: NCT02165397 (ClinicalTrials.gov).

Obesity is Associated With Greater Improvement in Patient-Reported Outcomes Following Primary Total Knee Arthroplasty.

BACKGROUND: Body mass index (BMI) cutoffs have been established for total knee arthroplasty (TKA) patients due to increased risk of medical complications in obese patients. However, evidence-based medical optimization may mitigate risk in these patients. This study examined the influence of BMI on patient-reported outcome measures (PROMs) following primary TKA with specialized perioperative optimization. METHODS: Between 2016 and 2020, 1,329 consecutive primary TKAs using standardized perioperative optimization were retrospectively reviewed. Patients were categorized into ordinal groups based on BMI in 5 kg/m2 increments (range, 17 to 61). Primary outcomes related to activity level, pain, function, and satisfaction were evaluated. BMI groups ≥35 had significantly lower age, more women, and higher prevalence of comorbidities (P ≤ .004). Mean follow-up was 1.7 years (range, 1 to 5 years). RESULTS: Each successive BMI group from 35 to ≥50 demonstrated continually greater improvement in pain with level walking and stair climbing (P ≤ .001), Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (P = .001), and greater satisfaction (P = .007). No patients who had a BMI ≥35 were revised for aseptic loosening, and rates of periprosthetic joint infection were not different between BMI groups (P = 1.000). CONCLUSION: Despite being more debilitated preoperatively, patients who had a BMI ≥35 experienced greater improvements in PROMs compared to patients who had lower BMI. Given the significant improvements in PROMs and quality of life in obese patients, with appropriate perioperative optimization, these patients should not be prohibited from having a TKA when appropriately indicated. LEVEL OF EVIDENCE: III.

Time Required for Planned and Unplanned Episodes of Care in Aseptic Hip and Knee Revision Arthroplasty.

BACKGROUND: Studies indicate aseptic revision total hip arthroplasty (rTHA) and revision total knee arthroplasty (rTKA) requires much more effort but is reimbursed less than primary procedures per minute work time. This study quantified planned and unplanned work performed by the surgeon and/or their team during the entire episode of care "reimbursement window" and compared it to allowed reimbursement times by Centers for Medicare and Medicaid Services (CMS). METHODS: Between October, 2010, and December, 2020, all unilateral aseptic rTHA and rTKA procedures performed by a single surgeon at a single institution were retrospectively reviewed. Time dedicated to planned work was calculated from surgery scheduling to 90 days postoperative. Impromptu patient inquiries and treatments after discharge but within the episode of care, involving the surgeon/surgeon team constituted unplanned work. Planned and unplanned work minutes were summed and divided by the number of patients reviewed to obtain average minutes of work per patient. Work time was compared to CMS allowable times for rTHA (617 minutes) and rTKA (520 minutes). RESULTS: There were 292 Aseptic rTKA and 63 aseptic rTHA procedures included. Based upon CMS allowable times per patient there were a mean of 4.4 hours (267 minutes) of uncompensated care time per rTKA patient and a mean of 2.4 hours (141 minutes) of uncompensated care time per rTHA patient. CONCLUSION: Aseptic revisions are substantially more complex than primaries, requiring work effort that is not commensurate with current reimbursements. Financially disincentivizing surgeons to care for patients requiring revision surgery could reduce patient access to care when high quality care is needed the most.

Patients With Previous COVID-19 Infection Can Safely Undergo Primary Total Joint Arthroplasty.

BACKGROUND: The COVID-19 virus is believed to increase the risk of diffusing intravascular coagulation. Total joint arthroplasty (TJA) is one of the most common elective surgeries and is also associated with a temporarily increased risk of venous thromboembolism (VTE). However, the influence of a history of COVID-19 infection on perioperative outcomes following TJA remains unknown. Therefore, this study sought to determine what effect a history of COVID-19 infection had on outcomes following primary TJA. METHODS: A retrospective case-control study using the national database was performed to identify all patients who had a history of COVID-19 and had undergone TJA, between 2019 and 2020. Patients who had a history of both were 1:1 matched to those who did not have a history of COVID-19, and 90-day outcomes were compared. A total of 661 TKA and 635 THA patients who had a history of COVID-19 were 1:1 matched to controls. There were no differences in demographics and comorbidities between the propensity-matched pairs in both TKAs and THAs studied. Previous COVID-19 diagnosis was noted in 28.3% of patients 5 days within TJA and in 78.6%, 90 days before TJA. RESULTS: Patients who had a previous diagnosis of COVID-19 had a higher risk of pneumonia during the postoperative period for both THA and TKA (6.9% versus 3.5%, P < .001 and 2.27% versus 1.21%, P = .04, respectively). Mean lengths of stay were also greater for those with a previous COVID-19 infection in both cohorts (TKA: 3.12 versus 2.57, P = .027, THA: 4.52 versus 3.62, P < .001). Other postoperative outcomes were similar between the 2 groups. CONCLUSION: COVID-19 infection history does not appear to increase the risk of VTE following primary TJA, but appears to increase the risk of pneumonia in addition to lengths of stay postoperatively. Individual risk factors should be discussed with patients, to set reasonable expectations regarding perioperative outcomes.

The Effect of Joint Line Elevation on Patient-Reported Outcomes After Contemporary Revision Total Knee Arthroplasty.

BACKGROUND: Joint line elevation in revision total knee arthroplasty (rTKA) is considered a risk factor for inferior outcomes, engendering a dogmatic protocol of joint line restoration. However, this precedent is based on historical data using rudimentary revision systems and unvalidated outcome measures. This study's purpose was to evaluate the effect of joint line height elevation on validated patient-reported outcome measures (PROMs) using modern revision implants. METHODS: A total of 327 rTKAs performed at a single institution were reviewed. Surgical technique prioritized flexion-extension gap balancing and accepted joint line elevation if necessary to achieve a balanced flexion space. Radiographic measurements included changes in joint line height (from preoperative and calculated "intended" anatomic/native) and change in posterior condylar offset. Prospectively collected PROMs were evaluated using multivariate regression. RESULTS: The mean joint line elevation from preoperative and "intended" to postoperative joint line was 4.9 ± 5.7 mm and 7.2 ± 6.6 mm, respectively. The mean increase in posterior condylar offset was 1.0 ± 4.6 mm. Patients within ±5 mm of preoperative joint line height were 3.88× more likely to achieve the substantial clinical benefit for Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (P = .004). An increase from intended joint line height >5 mm was not associated with differences in any other PROMs (P ≥ .165). CONCLUSIONS: In contemporary rTKA, recreating the joint line within 5 mm of preoperative improves knee-specific health outcomes. These data support approximating native joint line height as a viable technique to optimize flexion gap balance and subsequent patient outcomes in rTKA. LEVEL OF EVIDENCE: Level III retrospective cohort study.

The Fate and Relevance of the Patella in Two-Stage Revision Total Knee Arthroplasty for Periprosthetic Joint Infection.

BACKGROUND: It remains unclear whether reimplantation of a patellar component during a two-stage revision for periprosthetic total knee arthroplasty infection (PJI) affects patient reported outcome measures (PROMs) or implant survivorship. The purpose of this study was to evaluate whether patellar resurfacing during reimplantation confers a functional benefit or increases implant survivorship after two-stage treatment for PJI. METHODS: Two-stage revisions for knee PJI performed by three surgeons at a single tertiary care center were reviewed retrospectively. All original patellar components and cement were removed during resection and the patella was resurfaced whenever feasible during reimplantation. PROMs, implant survivorship, and radiographic measurements (patellar tilt and displacement) were compared between knees reimplanted with a patellar component versus those without a patellar component. RESULTS: A total of 103 patients met the inclusion criteria. Forty-three patients (41.7%) underwent reimplantation with, and 60 patients (58.3%) without a patellar component. At a mean follow-up of 33.5 months, there were no significant differences in patient demographics or PROMs between groups (P ≥ .156). No significant differences were found in the estimated Kaplan-Meier all-cause, aseptic, or septic survivorship between groups (P ≥ .342) at a maximum of 75 months follow-up. There was no significant difference in the change (pre-resection to post-reimplant) of patellar tilt (P = .504) or displacement (P = .097) between the groups. CONCLUSION: Patellar resurfacing during knee reimplantation does not appear to meaningfully impact postoperative PROMs or survivorship. Given the risk of potential extensor mechanism complications with patellar resurfacing, surgeons may choose to leave the patella without an implant during total knee reimplantation and expect similar clinical outcomes. LEVEL OF EVIDENCE: Level III.

Time Required for Planned and Unplanned Episodes of Care in Septic Two-Stage Revision Hip and Knee Arthroplasty.

BACKGROUND: Septic revision total hip (rTHA) and knee (rTKA) arthroplasty requires more effort but is reimbursed less than primary procedures per minute of intraoperative time. This study quantified planned and unplanned work performed by the surgical team for septic 2-stage revision surgeries during the entire episode-of-care "reimbursement window" and compared that time to allowable reimbursement amounts. METHODS: Between October 2010 and December 2020 all unilateral septic 2-stage rTHA and rTKA procedures performed by a single surgeon at a single institution were retrospectively reviewed. Time dedicated to planned work was calculated over each episode of care, from surgery scheduling to 90 days postoperatively. Impromptu patient inquiries and treatments after discharge, but within the episode of care, involving the surgeon/surgeon team constituted unplanned work. Planned and unplanned work minutes were summed and divided by the number of patients reviewed to obtain average minutes of work per patient. RESULTS: Sixty-eight hips and 64 knees were included. For 2-stage rTHA and rTKA the average time per patient for planned care was 1728 and 1716 minutes and for unplanned care was 339 and 237 minutes. Compared to the Centers for Medicare and Medicaid Services' allowable reimbursement times, an additional 799 and 887 minutes of uncompensated time was required to care for 2-stage rTHA and rTKA patients. CONCLUSION: Two-stage revision procedures are substantially more complex than primary procedures. Financially disincentivizing surgeons to care for these patients reduces access to care when high-quality care is most needed. These findings support increasing the allowable times for 2-stage septic revision cases.

Dually Insured Medicare/Medicaid Patients Undergoing Primary TJA Have More Comorbidities, Higher Complication Rates, and Lower Reimbursements Compared to Privately Insured Patients.

BACKGROUND: Dual eligibility status (DES: qualifying for both Medicare and a Medicaid supplement) was recently proposed by the Center for Medicare and Medicaid Services as a socioeconomic qualifier for risk adjustment in primary total joint arthroplasty. However, the profile and outcomes of DES patients have never been compared to privately insured patients. METHODS: A retrospective case-control study of the Mariner database within the PearlDiver server between 2010 and 2017 was performed. Patients aged 60 to 80 undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) (separately) were stratified based upon payer type: DES versus private payer. A propensity score-matched analysis with nearest neighbor pairing (1:1 ratio) was performed to compare 90-day outcomes and reimbursements. RESULTS: A total of 315,664 private and 3961 DES THA patients and 670,899 private and 2255 DES TKA patients were identified. DES patients were older and had a greater prevalence of comorbidities (31/36, P < .001). The THA DES matched cohort had greater transfusion rates (6.8% versus 3.9%, P < .001), higher 90-day emergency department visits (22.8% versus 16.3%, P < .001) and readmissions (16.8% versus 9.5%, P < .001), and lower reimbursements ($19,615 versus $13,036, P < .001). The TKA DES matched cohort had more cardiac events (0.4% versus 0.09%, P = .03), emergency department visits (25.2% versus 19.9%, P < .001), readmissions (14.4% versus 11.2%, P = .001), and reoperations (0.85% versus 0.35%, P = .03) CONCLUSION: DES patients have different comorbidity profiles, and even after propensity score matching have a greater risk of complications and are reimbursed less compared to privately insured patients. In the setting of alternative payment models, these differences should be accounted for through risk adjustment.

Designing delivery models of traditional and complementary medicine services: a review of international experiences.

BACKGROUND: The World Health Organization advocates integration of traditional and complementary medicine (T&CM) into the conventional health services delivery system. Integrating quality services in a patient-centred manner faces substantial challenges when T&CM is delivered within a health system dominated by conventional medicine. This review has synthesized international experiences of integration strategies across different contexts. SOURCES OF DATA: Publications describing international experiences of delivering T&CM service in conventional healthcare settings were searched. Backward and forward citation chasing was also conducted. AREAS OF AGREEMENT: Capable leaders are crucial in seeking endorsement from stakeholders within the conventional medicine hierarchy and regulatory bodies. However, patient demands for integrative care can be successful as demonstrated by cases included in this review, as can the promotion of the use of T&CM for filling effectiveness gaps in conventional medicine. Safeguarding quality and safety of the services is a priority. AREAS OF CONTROVERSY: Different referral mechanisms between conventional and T&CM practitioners suit different contexts, but at a minimum, general guideline on responsibilities across the two professionals is required. Evidence-based condition-specific referral protocols with detailed integrative treatment planning are gaining in popularity. GROWING POINTS: Interprofessional education is critical to establishing mutual trust and understanding between conventional clinicians and T&CM practitioners. Interprofessional communication is key to a successful collaboration, which can be strengthened by patient chart sharing, instant information exchange, and dedicated time for face-to-face interactions. AREAS TIMELY FOR DEVELOPING RESEARCH: Research is needed on the optimal methods for financing integrated care to ensure equitable access, as well as in remuneration of T&CM practitioners working in integrative healthcare.

Complications and Outcomes Associated With a Novel, Prefabricated, Articulating Spacer for Two-Stage Periprosthetic Joint Infection Treatment.

BACKGROUND: Various prefabricated articulating spacer options have been described for 2-stage treatment of chronic periprosthetic joint infection, but their results are poorly generalizable between designs due to differing antibiotic and material properties. This study reports outcomes for a novel, prefabricated, commercially available cement-on-cement articulating spacer. METHODS: A retrospective review of prospectively collected data for patients undergoing treatment with a prefabricated articulating cement spacer was performed. Outcomes were categorized as spacer complications, reimplantation rates, function, reinfection, and mortality. RESULTS: Seventy-six knees and 28 hips were analyzed. Spacer survival free of fracture, instability, or other implant-related complication until reimplantation was 100%. There were no bony or spacer fractures during the interstage or reimplantation. Reimplantation occurred in 84.6% of resected joints. Following spacer implantation, all but 1 patient was allowed to bear weight. The proportion of patients requiring an assistive device decreased from 67% prior to resection to 31% following reimplantation. Knee flexion improved from an average of 88.1° before resection to 111.9° following reimplantation. Eighty-seven percent of cases were infection free at mean follow-up of 16.6 ± 10.4 months. CONCLUSION: Study results demonstrate that this novel, prefabricated, articulating antibiotic spacer is safe, allows for good interstage function, and results in reasonable infection eradication rates at early term follow-up. LEVEL OF EVIDENCE: Therapeutic Level III.

Time Required for Planned and Unplanned Episodes of Care in Primary Total Joint Arthroplasty: Has Anything Changed With a Growth in Outpatient Arthroplasty?

BACKGROUND: This study sought to determine the total amount of time committed to planned and unplanned episodes of care related to primary, unilateral total joint arthroplasty (TJA), relative to a growth in outpatient TJA. METHODS: All primary, unilateral TJA procedures performed over a 7-year period by a single surgeon at a single institution were retrospectively reviewed. Time dedicated to planned work was calculated over each episode of care, from surgery scheduling to 90 days postoperatively. All telephone inquiries and readmissions involving the surgeon's direct input, over the episode of care, constituted time dedicated to unplanned work. RESULTS: Between 2012 and 2018, as the proportion of outpatient TJAs increased, the average planned episode-of-care time per patient decreased from 412 minutes to 361 minutes. Despite a 108% increase in the total number of outpatient TJAs between 2017 and 2018 (51/432 (11.8%) to 106/555 (19.1%); P = .002), neither the average number of unplanned telephone inquiries (4.6 ± 3.8 vs 4.2 ± 3.7; P = .124), nor the mean time per patient required to respond to calls (23.1 ± 19.4 vs 21.2 ± 18 minutes, P = .135) differed. Between 2017 and 2018, the average total episode-of-care time per patient decreased from 403 minutes (376 planned + 27 unplanned) to 387 minutes (361 planned + 26 unplanned). CONCLUSION: Despite an increase in outpatient TJA, the average time required for planned and unplanned patient care remained relatively constant. The growth of outpatient TJA nationally should not trigger a change in Centers for Medicare and Medicaid Services benchmarks.

Is There Benefit in Keeping Early Discharge Patients Overnight After Total Joint Arthroplasty?

BACKGROUND: Total joint arthoplasty (TJA) cost containment has been a key focus for the Centers for Medicare and Medicaid Services spawning significant research and programmatic change, including a move toward early discharge and outpatient TJA. TJA outpatients receive few, if any, medical interventions before discharge, but the type and quantity of interventions provided for TJA patients who stay overnight in the hospital is unknown. This study quantified the nature, frequency, and outcome of interventions occurring overnight after primary TJA. METHODS: 1725 consecutive primary unilateral TJAs performed between 2012 and 2017 by a single surgeon in a rapid-discharge program, managed by a perioperative internal medicine specialist, were reviewed. Medical records were examined for diagnostic tests, treatments, and procedures, results of interventions, and readmissions. RESULTS: 759 patients were discharged on postoperative day 1. Eighty-four percent (641 of 759) received no medical interventions during their overnight hospital stay. Twelve (1.6%) received diagnostic tests, 90 (11.9%) received treatments, and 29 (3.8%) received procedures. Ninety-two percent (11 of 12) of diagnostic tests were negative, 66% of 100 treatments in 90 patients were intravenous fluids for oliguria or hypotension, and all procedures were in and out catheterizations for urinary retention. 90-day all-cause readmission rates were similar in patients who received (2.5%) and did not receive (3.3%) a clinical intervention. CONCLUSION: Most patients received no overnight interventions, suggesting unnecessary costly hospitalization. The most common issues addressed were oliguria, urinary retention, and hypotension. Protocols to prevent these conditions would facilitate outpatient TJA, improve patient safety, and reduce costs.