Mississippi Kids Count: Early Childhood Education

Early education is crucial to supporting healthy childhood development and to providing a strong foundation for future schooling and general success. Defined as education between birth and age eight, early childhood education is associated with a wide range of positive outcomes for both the child as well as the community as a whole. Scientific studies suggest that participation in high quality early education, which includes elements such as trained and skilled teachers, small class sizes, and frequent child interaction and participation, improves cognitive and social development among all, but especially among low-income children. Research shows that children develop ninety percent of their adult-size brains in the first five years of life and therefore the provision of abundant information, proper stimulation and sufficient encouragement are keys to future success

Adverse outcomes after arthroscopic partial meniscectomy: a study of 700 000 procedures in the national Hospital Episode Statistics database for England

Background Arthroscopic partial meniscectomy is one of the most common orthopaedic procedures worldwide. Clinical trial evidence published in the past 6 years, however, has raised questions about the effectiveness of the procedure in some patient groups. In view of concerns about potential overuse, we aimed to establish the true risk of serious complications after arthroscopic partial meniscectomy. Methods We analysed national Hospital Episode Statistics data for all arthroscopic partial meniscectomies done in England between April 1, 1997, and March 31, 2017. Simultaneous or staged (within 6 months) bilateral cases were excluded. We identified complications occurring in the 90 days after the index procedure. The primary outcome was the occurrence of at least one serious complication within 90 days, which was defined as either myocardial infarction, stroke, pulmonary embolism, infection requiring surgery, fasciotomy, neurovascular injury, or death. Logistic regression modelling was used to identify factors associated with complications and, when possible, risk was compared with general population data. Findings During the study period 1 088 782 arthroscopic partial meniscectomies were done, 699 965 of which were eligible for analysis. Within 90 days, serious complications occurred in 2218 (0·317% [95% CI 0·304–0·330]) cases, including 546 pulmonary embolisms (0·078% [95% CI 0·072–0·085]) and 944 infections necessitating further surgery (0·135% [95% CI 0·126–0·144]). Increasing age (adjusted odds ratio [OR] 1·247 per decade [95% CI 1·208–1·288) and modified Charlson comorbidity index (adjusted OR 1·860 per 10 units [95% CI 1·708–2·042]) were associated with an increased risk of serious complications. Female sex was associated with a reduced risk of serious complications (adjusted OR 0·640 [95% CI 0·580–0·705). The risk of mortality fell over time (adjusted OR 0·965 per year [95% CI 0·937–0·994]). Mortality, myocardial infarction, and stroke occurred less frequently in the study cohort than in the general population. The risks of infection and pulmonary embolism did not change during the study, and were significantly higher in the study cohort than in the general population. For every 1390 (95% CI 1272–1532) fewer knee arthroscopies done, one pulmonary embolism could be prevented. For every 749 (95% CI 704–801) fewer procedures done, one native knee joint infection could be prevented. Interpretation Overall, the risk associated with undergoing arthroscopic partial meniscectomy was low. However, some rare but serious complications (including pulmonary embolism and infection) are associated with the procedure, and the risks have not fallen with time. In view of uncertainty about the effectiveness of arthroscopic partial meniscectomy, an appreciation of relative risks is crucial for patients and clinicians. Our data provide a basis for decision making and consent

Temporal trends and regional variation in the rate of arthroscopic knee surgery in England: analysis of over 1.7 million procedures between 1997 and 2017. Has practice changed in response to new evidence?

Objectives We investigated trends and regional variation in the rate of arthroscopic knee surgery performed in England from 1997–1998 to 2016–2017. Design Cross-sectional study of the national hospital episode statistics (HES) for England. Methods All hospital episodes for patients undergoing a knee arthroscopy between 1 April 1997 and 31 March 2017 were extracted from HES by procedure code. Age and sex-standardised rates of surgery were calculated using Office for National Statistic population data as the denominator. Trends in the rate of surgery were analysed by procedure both nationally and by Clinical Commissioning Group (CCG). Results A total of 1 088 872 arthroscopic partial meniscectomies (APMs), 326 600 diagnostic arthroscopies, 308 618 knee washouts and 252 885 chondroplasties were identified (1 759 467 hospital admissions; 1 447 142 patients). The rate of APM increased from a low of 51/100 000 population (95% CI 51 to 52) in 1997–1998 to a peak at 149/100 000 (95% CI 148 to 150) in 2013–2014; then, after 2014–2015, rates declined to 120/100 000 (95% CI 119 to 121) in 2016–2017. Rates of arthroscopic knee washout and diagnostic arthroscopy declined steadily from 50/100 000 (95% CI 49 to 50) and 47/100 000 (95% CI 46 to 47) respectively in 1997–1998, to 4.8/100 000 (95% CI 4.6 to 5.0) and 8.1/100 000 (95% CI 7.9 to 8.3) in 2016–2017. Rates of chondroplasty have increased from a low of 3.2/100 000 (95% CI 3.0 to 3.3) in 1997–1998 to 51/100 000 (95% CI 50.6 to 51.7) in 2016–2017. Substantial regional and age–group variation in practice was detected. In 2016–2017, between 11% (22/207) and 16% (34/207) of CCGs performed at least double the national average rate of each procedure. Conclusions Over the last 20 years, and likely in response to new evidence, rates of arthroscopic knee washout and diagnostic arthroscopy have declined by up to 90%. APM rates increased about 130% overall but have declined recently. Rates of chondroplasty increased about 15-fold. There is significant variation in practice, but the appropriate population intervention rate for these procedures remains unknown

Long-term rates of knee arthroplasty in a cohort of 834 393 patients with a history of arthroscopic partial meniscectomy

Aims The aim of this study was to determine the long-term risk of undergoing knee arthroplasty in a cohort of patients with meniscal tears who had undergone arthroscopic partial meniscectomy (APM). Patients and Methods A retrospective national cohort of patients with a history of isolated APM was identified over a 20-year period. Patients with prior surgery to the same knee were excluded. The primary outcome was knee arthroplasty. Hazard ratios (HRs) were adjusted by patient age, sex, year of APM, Charlson comorbidity index, regional deprivation, rurality, and ethnicity. Risk of arthroplasty in the index knee was compared with the patient’s contralateral knee (with vs without a history of APM). A total of 834 393 patients were included (mean age 50 years; 37% female). Results Of those with at least 15 years of follow-up, 13.49% (16 256/120 493; 95% confidence interval (CI) 13.30 to 13.69) underwent subsequent arthroplasty within this time. In women, 22.07% (95% CI 21.64 to 22.51) underwent arthroplasty within 15 years compared with 9.91% of men (95% CI 9.71 to 10.12), corresponding to a risk ratio (RR) of 2.23 (95% CI 2.16 to 2.29). Relative to the general population, patients with a history of APM were over ten times more likely (RR 10.27; 95% CI 10.07 to 10.47) to undergo arthroplasty rising to almost 40 times more likely (RR 39.62; 95% CI 27.68 to 56.70) at a younger age (30 to 39 years). In patients with a history of APM in only one knee, the risk of arthroplasty in that knee was greatly elevated in comparison with the contralateral knee (no APM; HR 2.99; 95% CI 2.95 to 3.02). Conclusion Patients developing a meniscal tear undergoing APM are at greater risk of knee arthroplasty than the general population. This risk is three-times greater in the patient’s affected knee than in the contralateral knee. Women in the cohort were at double the risk of progressing to knee arthroplasty compared with men. These important new reference data will inform shared decision making and enhance approaches to treatment, prevention, and clinical surveillance

Anterior cruciate ligament (ACL) reconstruction and meniscal repair rates have both increased in the past 20 years in England: hospital statistics from 1997 to 2017

Objectives We investigated the temporal trend and the geographical variation in the rate of an anterior cruciate ligament (ACL) reconstruction and meniscal repair (MR) performed in England during a 20-year window. Methods All hospital episodes for patients undergoing ACL reconstruction or MR between 1 April 1997 and 31 March 2017 were extracted by procedure code from the national hospital episode statistics. Age-standardised and sex-standardised rates of surgery were calculated using Office for National Statistics population data as the denominator and analysed over time both nationally and regionally by National Health Service clinical commissioning group (CCG). Results Between 1997–1998 and 2016–2017, there were 133 270 cases of ACL reconstruction (124 489 patients) and 42 651 cases of MR (41 120 patients) (isolated or simultaneous). Nationally, the rate of ACL reconstruction increased 12-fold from 2.0/100K population (95% CI 1.9 to 2.1) in 1997–1998 to 24.2/100K (95% CI 23.8 to 24.6) in 2016–2017. The rate of MR increased more than twofold from 3.0/100K (95% CI 2.8 to 3.1) in 1997–1998 to 7.3/100K (95% CI 7.1 to 7.5) in 2016–2017. Of these cases, the rate of simultaneous ACL reconstruction and MR was 2.6/100K (95% CI 2.5 to 2.8) in 2016/2017. In 2016–2017, for patients aged 20–29, the sex-standardised rate of ACL reconstruction was 76.9/100K (95% CI 74.9 to 78.9) and for MR was 19.8/100K (95% CI 18.8 to 20.9). Practice varied by region—in 2016–2017, 14.5% (30/207) of the CCGs performed more than twice the national average rate of ACL reconstruction and 15.0% (31/207) performed more than twice the national average rate of MR. Conclusions The rate of ACL reconstruction (12-fold) and MR (2.4-fold) has increased in England over the last two decades. There is variation in these rates across geographical regions and further work is required to deliver standardised treatment guidance for appropriate use

Arthroscopic partial meniscectomy for meniscal tears of the knee: a systematic review and meta-analysis

Objective To assess the benefit of arthroscopic partial meniscectomy (APM) in adults with a meniscal tear and knee pain in three defined populations (taking account of the comparison intervention): (A) all patients (any type of meniscal tear with or without radiographic osteoarthritis); (B) patients with any type of meniscal tear in a non-osteoarthritic knee; and (C) patients with an unstable meniscal tear in a non-osteoarthritic knee. Design Systematic review and meta-analysis. Datasources A search of MEDLINE, Embase, CENTRAL, Scopus, Web of Science, Clinicaltrials.gov and ISRCTN was performed, unlimited by language or publication date (inception to 18 October 2018). Eligibilitycriteria Randomised controlled trials performed in adults with meniscal tears, comparing APM versus (1) non-surgical intervention; (2) pharmacological intervention; (3) surgical intervention; and (4) no intervention. Results Ten trials were identified: seven compared with non-surgery, one pharmacological and two surgical. Findings were limited by small sample size, small number of trials and cross-over of participants to APM from comparator interventions. In group A (all patients) receiving APM versus non-surgical intervention (physiotherapy), at 6–12 months, there was a small mean improvement in knee pain (standardised mean difference [SMD] 0.22 [95% CI 0.03 to 0.40]; five trials, 943 patients; I2 48%; Grading of Recommendations Assessment, Development and Evaluation [GRADE]: low), knee-specific quality of life (SMD 0.43 [95% CI 0.10 to 0.75]; three trials, 350 patients; I2 56%; GRADE: low) and knee function (SMD 0.18 [95% CI 0.04 to 0.33]; six trials, 1050 patients; I2 27%; GRADE: low). When the analysis was restricted to people without osteoarthritis (group B), there was a small to moderate improvement in knee pain (SMD 0.35 [95% CI 0.04 to 0.66]; three trials, 402 patients; I2 58%; GRADE: very low), knee-specific quality of life (SMD 0.59 [95% CI 0.11 to 1.07]; two trials, 244 patients; I2 71%; GRADE: low) and knee function (SMD 0.30 [95% CI 0.06 to 0.53]; four trials, 507 patients; I2 44%; GRADE: very low). There was no improvement in knee pain, function or quality of life in patients receiving APM compared with placebo surgery at 6–12 months in group A or B (pain: SMD 0.08 [95% CI −0.24 to 0.41]; one trial, 146 patients; GRADE: low; function: SMD −0.08 [95% CI −0.41 to 0.24]; one trial, 146 patients; GRADE: high; quality of life: SMD 0.05 [95% CI −0.27 to 0.38]; one trial; 146 patients; GRADE: high). No trials were identified for people in group C. Conclusion Performing APM in all patients with knee pain and a meniscal tear is not appropriate, and surgical treatment should not be considered the first-line intervention. There may, however, be a small-to-moderate benefit from APM compared with physiotherapy for patients without osteoarthritis. No trial has been limited to patients failing non-operative treatment or patients with an unstable meniscal tear in a non-arthritic joint; research is needed to establish the value of APM in this population

Mortality and adverse joint outcomes following septic arthritis of the native knee:a longitudinal cohort study of patients receiving arthroscopic washout

BACKGROUNDThe short and long-term consequences of septic arthritis are uncertain. The purpose of this study was to determine the risk of mortality and adverse joint outcomes following septic arthritis of the native knee.METHODSA retrospective cohort study of patients undergoing knee washout for septic arthritis, without prior knee surgery, was performed utilising the national hospital database for England over twenty-years. The rate of mortality within 90-days, and the 1-year and long-term rate of adverse joint outcomes (arthrodesis, amputation, arthroplasty), was determined. The mortality rate for patients with a primary admitting diagnosis of septic arthritis (ICD-10; M00) was compared to cases where this was a secondary diagnosis.FINDINGS12132 patients were included (mean age 56.6 years; SD 24.9; 36% [4307/12132] female). Of the 10195 (84%) cases with septic arthritis as the primary admitting diagnosis, the 90-day mortality rate was 7.05% (719/10195; 95% CI 6.56-7.57) rising to 22.69% (418/1842; 95% CI 20.80-24.68) for patients aged over 79-years. Secondary septic arthritis was associated with adjusted odds for mortality of 2.10 (odds ratio; 95% CI1.79-2.46; p<0.001). The 1-year rate of arthrodesis was 0.13% (15/11393; 95% CI 0.07-0.22), amputation 0.40% (46/11393; 95% CI 0.30-0.54), and arthroplasty 1.33% (152/11393; 95% CI 1.13-1.56). Within 15-years, 8.76% (159/1816; 95% CI 7.50-10.15) underwent arthroplasty, corresponding to an annual risk of 6.14 times (risk ratio; 95% CI 4.95-7.62; p<0.001) that of the general population.INTERPRETATIONThe consequences of septic knee arthritis (in a cohort of patients undergoing arthroscopic knee washout) are serious, with a 7% risk of mortality within 90-days, greater than 1% risk of adverse joint outcomes within 1-year, and 9% risk of knee arthroplasty within 15-years. These findings highlight the potentially devastating outcomes associated with sepsis from musculoskeletal joint infection

Rates of knee arthroplasty in patients with a history of arthroscopic chondroplasty:results from a retrospective cohort study utilising the National Hospital Episode Statistics for England

Objective: The purpose of this study was to analyse the rate of knee arthroplasty in the population of patients with a history of arthroscopic chondroplasty of the knee, in England, over 10 years, with comparison to general population data for patients without a history of chondroplasty. Design: Retrospective cohort study. Setting: English Hospital Episode Statistics (HES) data. Participants and Interventions: Patients undergoing arthroscopic chondroplasty in England between 2007/2008 and 2016/2017 were identified. Patients undergoing previous arthroscopic knee surgery or simultaneous cruciate ligament reconstruction or microfracture in the same knee were excluded. Outcomes: Patients subsequently undergoing a knee arthroplasty in the same knee were identified and mortality-adjusted survival analysis was performed (survival without undergoing knee arthroplasty). A Cox proportional hazards model was used to identify factors associated with knee arthroplasty. Relative risk of knee arthroplasty (total or partial) in comparison to the general population was determined. Results: Through 2007 to 2017, 157 730 eligible chondroplasty patients were identified. Within 1 year, 5.91% (7984/135 197; 95% CI 5.78 to 6.03) underwent knee arthroplasty and 14.22% (8145/57 267; 95% CI 13.94 to 14.51) within 5 years. Patients aged over 30 years with a history of chondroplasty were 17.32 times (risk ratio; 95% CI 16.81 to 17.84) more likely to undergo arthroplasty than the general population without a history of chondroplasty. Conclusions: Patients with cartilage lesions of the knee, treated with arthroscopic chondroplasty, are at greater risk of subsequent knee arthroplasty than the general population and for a proportion of patients, there is insufficient benefit to prevent the need for knee arthroplasty within 1 to 5 years. These important new data will inform patients of the anticipated outcomes following this procedure. The risk in comparison to non-operative treatment remains unknown and there is an urgent need for a randomised clinical trial in this population