Pre-operative Emotional Health Affects Post-operative Patient Function but not Patient Satisfaction Following Primary Total Hip Arthroplasty

Introduction: Total hip (THA) and knee (TKA) arthroplasty are highly successful treatments for end-stage arthritis. However, a subset of patients experience suboptimal post-operative gain in function. 1, 2 Previous studies have shown that pre-operative emotional health influences outcomes after TKA,3 but there is limited evidence on THA patients. We hypothesized that pre-operative emotional health does not affect patient satisfaction in THA patients. Methods: A secondary analysis of an existing registry at UMass of primary THA patients between 2008 and 2011 was conducted. Baseline demographic, clinical, emotional health (SF-36 MCS), and physical health (SF-36 PCS) data were collected electronically at the pre-operative visit. Post-operative SF-36 MCS, SF-36 PCS, and satisfaction scores were collected electronically between 6 months through 2 years follow-up. Bivariate analyses and multivariate logistic regression models were used. Results: The analysis included 316 primary THA patients with mean age 62±11 years, 55% female, mean BMI 30±5, mean PCS 31±8, and mean MCS 51±11. Patients with lower baseline emotional health scores reported significantly reduced mean post-operative physical function and emotional health (p45 (indicating excellent function, national norm = 50); whereas patients with baseline MCS≥50 had a mean 17±11 point increase in post-operative PCS with 71% of these patients reporting PCS\u3e45 (p\u3c0.001). Conclusion: In THA patients, post-operative emotional health and physical health are positively correlated with baseline emotional health, however post-operative patient satisfaction remains independent of baseline emotional health

Importance of clinically-refined medical and musculoskeletal co-morbidities in registries that evaluate patient-reported outcomes following TKR

BACKGROUND: As national joint registries broaden their focus to include patient-reported outcomes, such as pain relief and functional gain, the role of confounding peri-operative complications and co-morbidities must be considered. We hypothesized that emotional, medical, and musculoskeletal co-morbidities influence post-surgical functional gain following primary total knee (TKR) replacement surgery. METHODS: We performed secondary analyses of comprehensive data from 180 primary TKR patients to evaluate the association of age, sex, body mass index (BMI), pre-operative emotional health (SF36 MCS/metal component score and CES-D depression screen), medical comorbidities (modified Charlson index), and musculoskeletal comorbidities (pain in low back, hips, and knees) on change in pre-to-6 month post-TKR physical function (SF36 PCS/physical component score). RESULTS: Patients were 68% female with mean age of 65 years, mean BMI of 32. Mean pre-TKR PCS was 32.0 (SE=0.65), mean MCS was 52.0 (SE= 0.46) and 32% reported pre-TKR CES-D score at the mild to moderate depression level. Musculoskeletal comorbidity was scored as percent of patients with moderate or severe pain; 12% had hip pain, 46% contra-lateral knee pain, 27% low back pain, and 12% foot pain. Six percent reported COPD, 7% cardiac conditions, and 3% renal conditions. A multivariate linear regression model showed BMI\u3e30, lower pre-MCS, lower pre-PCS, moderate or severe low back pain, and higher Charlson co-morbidity score, to be significantly (p CONCLUSION: Pre-operative BMI, emotional health, and medical and musculoskeletal co-morbidities are required to interpret pre-to-post-operative change in physical function. Further understanding of the role of these factors is critical before national registries can analyze and report valid comparisons of patient-reported outcomes

Level of Pain and Disability at Time of TKR across the Past 10 Years: Results from Two National Cohorts

Introduction: A recent analysis reported a growing numbers of younger US adults with knee pain consistent with osteoarthritis (OA), although parallel analyses of knee x-rays found no increase in the classic radiographic signs of OA. The accompanying editorial evoked the need to understand if surgeons are performing surgery at an earlier stage in the condition.1 We compared pre-operative demographic and symptom profiles of a national US cohort of OA patients undergoing primary total knee replacement (TKR) in 2011-2012 with a national US cohort of patients from 2000-2004 to evaluate change, if any, in the timing of surgery as measured by patient pain and function. Methods: Following informed consent, the 2011-2012 national research study collected comprehensive data including demographic, comorbidity, and patient-reported pain and physical function, from a national sample of TKR patients. Comparable data from a national sample collected by one implant manufacturer between 2000-2004 were analyzed. Descriptive statistics compared the demographic and symptom profiles of the two cohorts. Results: There were fewer females in the 2011-2012 cohort (n=2363) compared to the 2000-2004 cohort (n=7144) (61.62%, vs. 66.72%). The 2011-2012 cohort was younger than the 2000-2004 cohort (66.7 years, vs. 68.12 years) and had a lower mean BMI (31.5 vs 32.3). Pre-operative physical function scores (SF36/PCS) were 3 points higher in 2011-2012 than 2000-2004 (33.2 vs. 30.41). When compared to the national PCS norm of 50 (SD=10), TKR patients from both time periods reported pre-operative function levels almost 2 standard deviations below the national norm. There was no significant difference in terms of emotional health (SF36/MCS scores: 51.85 for the 2011-2012 cohort vs. 51.83 for the 2000-2004 cohort). Conclusion: Despite the significant growth in the use of primary TKR in the last decade, especially among younger patients, TKR patients continue to report significant disability at the time of surgery

Clinical Profile and Disability Levels of Younger vs. Older TKR and THR Patients in a National Research Consortium

Introduction: A growing number of patients under 65 years old undergo total knee replacement (TKR) and total hip replacement (THR).1 This trend has raised concerns that younger patients may receive surgery prematurely. We examined demographic and clinical factors in younger versus older patients in a national sample of THR and THR patients. Methods: Patients undergoing primary TKR and THR from 7/1/11 through 12/03/12 were identified from a national research consortium that gathers demographics, comorbid conditions (Charlson Comorbidity Index), Short Form 36 Physical Component Score (PCS) and Mental Component Score (MCS), burden of musculoskeletal disease using the Knee injury and Osteoarthritis Outcome Score (KOOS) or the Hip injury and Osteoarthritis Outcome Score (HOOS) and the Oswestry Low Back Pain Disability Questionnaire. Descriptive statistics were performed. Results: TKR patients included 1326 younger ( Conclusion: Younger patients have fewer medical illnesses at the time of TKR or THR, but have greater functional impairment and higher rates of obesity and smoking as well as lower mental health scores

Differences Between Women and Men Undergoing TKR and THR in a National Research Consortium

Introduction: Prior studies reported higher prevalence of arthritis, greater disability, lower rate of utilization of total knee replacement (TKR) and total hip replacement (THR) in women as compared to men, as well as differences in outcomes after surgery. We examined sex differences in terms of demographic and clinical factors that influence surgical outcomes in a national sample of patients who underwent TKR or THR. Methods: Patients undergoing primary THR and TKR from 7/1/11 through 12/03/12 were identified from a national research consortium that gathers demographic data, the Western Ontario and McMaster Universities Arthritis Index (WOMAC) estimated from the Knee injury and Osteoarthritis Outcome Score (KOOS) or the Hip injury and Osteoarthritis Outcome Score (HOOS), Short Form 36 Physical Component Score (PCS) and Mental Component Score (MCS) and musculoskeletal burden of illness. Descriptive statistics were performed. Results: Primary TKR patients included 2042 women and 1276 men. Women were more likely nonwhite (11.2% vs. 7.5%), unmarried (40.3% vs. 17.8%), lower income (p Conclusion: In this national sample, women undergoing primary THR and TKR have more severe arthritis, greater functional impairment and greater burden of musculoskeletal disease as compared to men. Understanding these differences will help tailor peri-operative care to the needs of the patients

Poor Pre-Operative Emotional Health Limits Gain in Function after Total Hip Replacement

Introduction: While total joint replacement surgery successfully reduce joint pain and is associated with a low complication rate, patients experience a wide variation in functional improvement. Pre-surgery emotional state correlates with post-surgical functional improvement in total knee replacement patients. We tested this concept against a national cohort of total hip replacement (THR) patients. Materials & methods: Patients undergoing primary THR from 7/1/11 through 12/6/13 with postoperative outcomes at 6 months were identified from FORCE-TJR, a US national research consortium. We obtained data on patient demographics, underlying type of arthritis, body mass index (BMI), Charlson Comorbidity Index, arthritic pain in contralateral hip and bilateral knees, back pain, Hip Disability and Osteoarthritis Outcome Score (HOOS), global function based on the Short Form 36 (SF-36) Physical Component Score (PCS) and emotional health using the SF-36 Mental Component Score (MCS). We performed descriptive statistics and multivariable linear regression models to identify factors associated with 6-month postoperative PCS global function scores. Results: The 1,426 THR patients identified were 60.7% female, 95.0% white, mean age 65.3 years, mean BMI of 29.0. Mean preoperative surgical joint pain, stiffness and function was 50.1 (± 19.2), 38.7 (± 21.9), 46.4 (±19.2) respectively. MCS was 51.56 (± 12.2) and PCS 31.6 (± 8.9). Pre-operative and post-operative functioning differed based on emotional health (MCS ≥50). In multivariable models, lower MCS levels were associated with worse PCS at 6 months (coefficient of 0.18. 95% CI 0.14-0.22) after controlling for demographics, medical comorbidity, baseline PCS and burden of musculoskeletal disease. Conclusion: Poorer emotional health is associated with poorer global function following surgery and a key factor in the recovery and rehabilitation following THR. Better emotional health screening for THR surgical candidates, and interventions to provide additional emotional support to those who need it, are necessary to ensure optimal functional gain

Revisiting the Rise of Electronic Nicotine Delivery Systems Using Search Query Surveillance

Public perceptions of electronic nicotine delivery systems (ENDS) remain poorly understood because surveys are too costly to regularly implement and when implemented there are large delays between data collection and dissemination. Search query surveillance has bridged some of these gaps. Herein, ENDS’ popularity in the U.S. is reassessed using Google searches

Tantalum versus Titanium Acetabular Shells in Young Active THR Patients: A Radiostereometric Analysis (RSA) Study

Introduction: In the active THR (total hip replacement) population, acetabular component stability is crucial for preventing implant failure. Titanium fiber metal coating is the most common material used in cementless THR. Trabecular metal, composed of porous tantalum, is designed to improve tissue infiltration and limit migration. It is unknown if tantalum offers an advantage over titanium in the biologic fixation of porous-coated acetabular shells. Radiostereometric analysis (RSA) provides highly precise measurements of micromotion that are otherwise not detectable by routine radiographs. Methods: In this IRB approved, prospective, randomized, blinded study, 46 patients received a primary THR by a single surgeon. Each patient was randomized to receive a titanium (23) or tantalum (23) uncemented cup. Tantalum RSA markers were implanted around the polyethylene liner and into the patient’s femur and periacetabular bone. Also, patients received either a highly cross-linked (n=25) or a conventional liner (n=21). RSA examinations, Harris Hip, UCLA, WOMAC, SF-12 scores were obtained at 10 days, 6 months, and annually through 5 years. Results: The randomized groups had comparable mean age, preoperative activity, and average BMI. The tantalum shells demonstrated less median translation than the titanium shells at each time-point, but there was no statistical difference between the two shells. At 6 months median translation of tantalum and titanium was -0.01mm and 0.04mm and remained stable with median translation of -0.02mm and 0.04mm at four years. Mean UCLA, WOMAC, Harris Hip, and SF-12 PCS and MCS scores improved similarly in both groups. Conclusions: After THR, both patient cohorts had excellent clinical outcomes with statistically significant improvements in function and pain relief. Although tantalum porous-coated acetabular shells demonstrated less y-translation and y-rotation at all time points, there was no statistically significant difference in shell migration and both shells demonstrated excellent stability with minimal micromotion at four years

FORCE-TJR: Innovative design for a national TJR comparative effectiveness research database

BACKGROUND: Joint replacement (TJR) registries have traditionnally focused on collecting implant data and analyzing time-to-revision. Sub-optimal outcomes short of revision are important to surgeons and patients. In 2010, the US federal Agency for Healthcare Research and Quality funded Function and Outcomes Research for Comparative Effectiveness in TJR (FORCE-TJR), a research consortium and database to collect comprehensive TJR outcomes, including patient-reported pain and function and post-operative sequelae. This $12 million research award will provide new information about post-TJR adverse events, patient-reported functional gain, and implant longevity. We developed novel methods to assure critical data collection and sustainability. METHODS: FORCE-TJR developed methods to (1) assemble a research consortium that includes a national sample of diverse surgeons and practices who agree to invite all patients to participate, (2) implement a virtual model for patient consent and data entry of consistent, validated patient-reported surveys, (3) conduct efficient screening for post-TJR sequelae and validated chart review and adjudication, and (4) document implant details. RESULTS: In the first 8 months, FORCE-TJR enrolled more than 90 surgeons in urban and rural settings, across 21 states; with academic, private, and HMO ownership; performing varied annual volumes of TJR surgery. Across practices, 80-95% of patients enrolled and more than 3250 patients consented to complete standardized surveys. More than 150 patients are enrolled each week, and enrollment rates will grow as additional surgeons join. CONCLUSION: FORCE-TJR employs innovative strategies to collect comprehensive post-TJR data from a national cohort of more than 30,000 patients. Comparative effectiveness research emerging from these data will include patient, implant, health system predictors of post-TJR adverse events, pain relief, functional gain, and revision. These TJR analyses will offer novel and important new evidence to guide patient and surgeon decisions, and are possible only because of this comprehensive research design

Prediction of Dengue Incidence Using Search Query Surveillance

Improvements in surveillance, prediction of outbreaks and the monitoring of the epidemiology of dengue virus in countries with underdeveloped surveillance systems are of great importance to ministries of health and other public health decision makers who are often constrained by budget or man-power. Google Flu Trends has proven successful in providing an early warning system for outbreaks of influenza weeks before case data are reported. We believe that there is greater potential for this technique for dengue, as the incidence of this pathogen can vary by a factor of ten in some settings, making prediction all the more important in public health planning. In this paper, we demonstrate the utility of Google search terms in predicting dengue incidence in Singapore and Bangkok, Thailand using several regression techniques. Incidence data were provided by the Singapore Ministry of Health and the Thailand Bureau of Epidemiology. We find our models predict incident cases well (correlation greater than 0.8) and periods of high incidence equally well (AUC greater than 0.95). All data and analysis code used in our study are available free online and can be adapted to other settings