Veterans RAND 12-Item Health Survey Research Articles

The association between physical health-related quality of life, physical functioning, and risk of contralateral breast cancer among older women.

Physical limitations prior to cancer diagnosis may lead to suboptimal health outcomes. Our objective was to evaluate the impacts of poor physical health-related quality of life (HRQOL) and physical functioning (PF) on the risk of contralateral breast cancer (CBC). We performed a nested case-control study of women with invasive unilateral breast cancer (UBC) who did not receive prophylactic contralateral mastectomy using the Surveillance, Epidemiology and End Results Medicare Health Outcomes Survey data resource. Among 2938 women aged ≥ 65years diagnosed with first stage I-III UBC between 1997 and 2011, we identified 100 subsequent CBC cases and 915 matched controls without CBC using incidence density samplingwithout replacement. Pre-diagnosis physical HRQOL and PF were determined using Medical Outcomes Trust Short Form-36 (SF-36)/Veterans Rand 12-Item Health Survey (VR-12) responses within 2years prior to first UBC diagnosis. We estimated adjusted odds ratios (OR) and 95% confidence intervals (CI) using conditional logistic regression models. Cases and controls were similar with respect to comorbidities, stage, surgery, and radiation treatments, but differed by hormone receptor status (ER/PR-negative, 23% and 11%, respectively) of first UBC. Cases had modestly lower mean pre-diagnosis physical HRQOL (-1.8) and PF (-2.2) scores. In multivariable models, we observed an increased CBC risk associated with low physical HRQOL (lowest vs. highest quartile, OR = 1.8; 95% CI 0.8-4.3), but CIs included 1.0. Low PF was associated with a 2.7-fold (95% CI 1.1-6.7) increased CBC risk. Findings indicate that low physical HRQOL, specifically poor PF, is associated with CBC risk. Efforts to understand and minimize declines in PF post-breast cancer are well motivated.

Postoperative Doxycycline Did Not Improve Early Postoperative Outcomes in Hip Arthroscopy Patients: A Retrospective Cohort Study

AbstractDoxycycline has been shown to reduce fibroblast activity in the treatment of multiple pathologies, and was utilized as part of the postoperative medication protocol to help prevent adhesions from developing after hip arthroscopy. The purpose of this study was to compare early postoperative pain outcomes between consecutive case series of femoroacetabular impingement syndrome (FAIS) patients treated with or without a 7-day postoperative course of doxycycline following hip arthroscopy. We hypothesized that the doxycycline-treated group would have superior patient-reported outcomes at 6 weeks, and the effect would be more pronounced for patients with low preoperative mental health scores.Our institutional review board–approved prospective outcomes registry was queried for patients who had undergone arthroscopic femoral osteochondroplasty and/or labral repair or reconstruction secondary to FAIS performed by a single, fellowship-trained surgeon. A 7-day postoperative course of doxycycline was initiated in 2018. Six-week postoperative Hip Disability and Osteoarthritis Outcome Score (HOOS) global (HOOSglobal) and International Hip Outcome Tool (iHOT) scores were compared between the consecutive series treated with versus without doxycycline. Additional subgroup analysis was performed on patients with low preoperative Veterans RAND 12-Item Health Survey (VR-12) mental component scores to determine possible additional benefit of postoperative doxycycline in this group.A total of 134 patients (98 female, 36 male, age = 36.2 ± 13.4 years, body mass index [BMI] = 27.2 ± 5 kg/m2) were identified between 2013 and 2020. There were no differences between the control (n = 84) and doxycycline group (n = 50) in age, sex, or BMI. Postoperative HOOSglobal scores (control = 58.5 ± 13.1, doxycycline = 58.7 ± 14.7, p = 0.96) and iHOT scores (control = 54.4 ± 22.2, doxycycline = 52.3 ± 24.8, p = 0.61) did not differ between groups. The subset of 83 patients with low preoperative mental scores showed no differences in HOOSglobal (control = 51.6 ± 13.3, doxycycline = 57.3 ± 7.4, p = 0.12) or iHOT scores (control = 45.5 ± 20.3, doxycycline = 53.6 ± 23.1, p = 0.250).Our results do not support the hypothesis that postoperative doxycycline leads to significant improvement in early postoperative pain scores or functional outcomes in patients undergoing hip arthroscopy for FAIS.

Health Conditions, Substance Use, Physical Activity, and Quality of Life in Current and Former Baseball Players.

Background:A comprehensive understanding of lifestyle (health conditions and substance use), health-related quality of life (HRQoL), flourishing (holistic representation of health), and physical activity can inform stakeholders (players, coaches, and clinicians) and help improve long-term health across the life span.Purpose:To describe health conditions (comorbidities or diagnoses), substance use, physical activity, HRQoL, and flourishing in current and former collegiate and professional baseball players and to assess the relationship between playing position and HRQoL/flourishing in former baseball players.Study Design:Descriptive epidemiology study.Methods:Eligible participants were those ≥18 years old with ≥1 season of collegiate or professional baseball experience. Participants completed a survey on health conditions (asthma, diabetes, hypertension, hypercholesterolemia, and depression), substance use (tobacco, alcohol, and energy drinks), physical activity (International Physical Activity Questionnaire–Short Form), HRQoL (Veterans Rand 12-Item Health Survey [VR-12] physical and mental component scores), and flourishing (Flourishing Scale). Adjusted multivariable regressions were performed for HRQoL and flourishing.Results:Overall, 260 baseball players opened the survey, and 214 (current players, 97; former players, 117) participated for an 82% response rate. Of the former players, 32% had hypertension or hypercholesterolemia. In addition, 26% of current players had used smokeless tobacco (median, 3 years; interquartile range [IQR], 1-5 years) as compared with 34% of former players (median, 15 years; IQR, 5-25 years). In addition, 14% of current players had used electronic cigarettes (median, 2 years; IQR, 0-4 years) as opposed to 3% of former (median, 3 years; IQR, 2-4 years). Energy drinks were consumed by 31% and 14%, respectively, of current and former players on at least a weekly basis. Current baseball players performed 8667 metabolic equivalents per week of physical activity as opposed to 3931 in former players. Pitching was associated with worse VR-12 Mental Component Scores (–5.0; 95% confidence interval, –9.0 to –1.0). Playing position was not related to VR-12 Physical Component Scores or flourishing in former baseball players.Conclusion:The similar smokeless tobacco prevalence between current and former baseball players suggests that they may start using tobacco products during baseball participation and continue after retirement. Similar reported HRQoL as compared with the general US population and high flourishing and physical activity levels suggest that baseball players may present with good musculoskeletal and psychological health.

Impact of Prediagnosis Risk of Major Depressive Disorder and Health-Related Quality of Life on Treatment Choice for Stage II-III Rectal Cancer

We hypothesized that depressive symptoms and health-related quality of life (HRQOL) reported by patients prior to their cancer diagnoses would be associated with treatment choice for stage II and III rectal cancer. During the period of study and at the time of this writing, the standard of care for stage II-III rectal cancer has been neoadjuvant radiation followed by surgical resection with or without adjuvant chemotherapy.The SEER and Medicare Health Outcomes Survey (SEER-MHOS) linked dataset was used to identify patients with stage II and III rectal adenocarcinoma diagnosed between 2004 and 2013 who had completed the health outcomes survey within 36 months before their cancer diagnoses. Risk for major depressive disorder (MDD) was determined based on responses to screening questions for depressive disorders. HRQOL was assessed using the Mental Component Summary (MCS) and Physical Component Summary (PCS) of the 36-Item Short Form Survey (SF-36) and the Veterans RAND 12-Item Health Survey (VR-12). Using both univariable and multivariable analysis to control for potentially confounding patient characteristics, we assessed for associations between these health survey responses and ultimate treatment choice, specifically regarding whether patients underwent surgery for their rectal cancer.We identified 142 evaluable patients with stage II-III rectal cancer, of whom 109 (76.8%) underwent surgery. Thirty patients (21.1%) met criteria for being at risk for MDD before their cancer diagnoses. Patients at risk for MDD were significantly less likely to undergo surgery than those not at risk (63.3% vs. 80.4%, P = 0.0499), and this association strengthened after adjusting for patient characteristics (OR 0.17, 95% CI 0.04-0.82, P = 0.027). There was a nonsignificant trend between higher MCS scores (equating with higher self-reported mental HRQOL) and increased likelihood of undergoing surgery (P = 0.081). There were no significant associations between the PCS and treatment modality.In patients with stage II-III rectal cancer, there was a significant association between prediagnosis risk of MDD and treatment choice, such that patients at risk for MDD were less likely to undergo standard-of-care treatment with surgery. Further studies are warranted to assess the effect of MDD risk and HRQOL on clinical decision making with this patient population.

Patients with diabetes mellitus experience poorer outcomes after arthroscopic rotator cuff repair

HypothesisThe purpose of this study was to identify potential differences using validated clinical outcome instruments between patients with and without diabetes mellitus (DM) after arthroscopic rotator cuff repair (RCR).MethodsSix-hundred eighty-four patients (32 with and 652 without DM) who underwent arthroscopic RCR were prospectively followed using the visual analog pain scale, Simple Shoulder Test, Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons score, and Veterans RAND 12-item Health Survey (mental and physical component scores) preoperatively and at 3, 6, 12, and 24 months postoperatively.ResultsPatients with DM experienced significantly more pain (P = .0172) and had lower Simple Shoulder Test (P = .0458) and American Shoulder and Elbow Surgeons (P = .0200) scores than patients without DM 6 months after surgery. Although differences between groups are seen at other postoperative time points, none are statistically significant.They also exhibited lower self-rated mental health status at 12 months (P = .0034) and 24 months (P = .0077), as well as lower self-rated physical health status at 12 months (P = .0223) and 24 months (P = .0077). Changes in scores from preoperatively to postoperatively were not different for patients with DM vs. without DM.ConclusionPatients with DM experience significantly more pain, exhibit significantly poorer shoulder function, and report persistently diminished mental and physical health status compared with their counterparts without DM after undergoing arthroscopic RCR. Although these differences did not reach the minimal clinically important difference, orthopedic surgeons should be cognizant of DM as an outcome-modifying variable when selecting, counseling, and treating patients with rotator cuff tears. Glycemic control should be scrutinized and optimized during the perioperative medical evaluation and ultimately factored into the surgical risk profile and prognosis.

Preoperative Opioid Use Predicts Postoperative Opioid Use and Inferior Clinically Notable Outcomes After Total Shoulder Arthroplasty.

Preoperative opioid use (OU) may negatively affect outcomes after total shoulder arthroplasty (TSA). This study aims to evaluate the influence of preoperative OU on achievement of midterm clinically notable outcomes (CSOs) after TSA and identify factors associated with prolonged postoperative OU and persistent pain after TSA. Using a single-institution, prospectively collected TSA registry, we retrospectively identified patients who underwent surgery between 2014 and 2019. Subjects were stratified into two cohorts: preoperative OU within 12 months of surgery and opioid naive (N-OU) patients. Minimum 1-year postoperative scores and achievement of CSOs patient-reported outcome measures (PROMs), as well as predictors of postoperative OU and persistent pain, were analyzed. A total of 817 patients were included with 706 patients in the N-OU cohort and 111 patients in the OU cohort. Although both patients in the N-OU and OU cohorts showed statistically significant improvements at the 1-year follow-up, absolute PROM scores were less favorable in the OU cohort (all P < 0.05). Preoperative opioid users were significantly less likely to achieve minimal clinically important difference (odds ratios [ORs]: 0.47 to 2.4, all P < 0.05) and patient acceptable symptomatic state (ORs: 0.41 to 2.12, all P < 0.05) on the American Shoulder and Elbow Surgeon, Single Assessment Numeric Evaluation, Constant-Murley Shoulder Score, Visual Analogue Scale (VAS) pain, Veterans Rand 12-Item Health Survey, Short-Form 12-Item Health Survey, and Veterans Rand 6D and substantial clinical benefit (OR: 0.50 to 0.56, P < 0.05) on the American Shoulder and Elbow Surgeon and Single Assessment Numeric Evaluation. Preoperative OU significantly predicted increased OU at 6 months (OR: 7.11, P = 0.009) and 1-year follow-up (OR: 40.23, P < 0.001) and persistent pain at 1 year (OR: 2.37, P = 0.001). Preoperative OU markedly correlated with worse PROMs at 1 year postoperatively. Although preoperative opioid users demonstrate improvement in functional-related and health-related quality-of-life PROMs after TSA, they are markedly less likely to achieve CSOs and were more likely to report persistent pain and continued OU at 6-month and 1-year follow-ups. Opioid users undergoing TSA should be counseled regarding their expected outcomes, and preventive measures should aim to limit prolonged OU/abuse after surgery. Level III, retrospective cohort study.

Short-term Outcomes of Concomitant Femoral Derotation Osteotomy and Hip Arthroscopy.

The goal of this study is to report the short-term outcomes of concomitant hip arthroscopy and femoral derotational osteotomy (FRO) to treat femoral malrotation and intra-articular pathology. Data were retrospectively reviewed for patients undergoing concomitant hip arthroscopy and FRO between March 2013 and January 2017. Patients were included if they had a minimum of 1 year of follow-up for modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), International Hip Outcome Tool (iHOT-12) score, 12-item Short Form Health Survey Physical component and Mental component (SF-12 P and SF-12 M, respectively) scores, Veterans RAND 12-item Health Survey Physical and Mental (VR-12 P and VR-12 M, respectively) scores, visual analog scale (VAS) score for pain, and patient satisfaction ratings. Rates for meeting the patient acceptable symptomatic state (PASS) and minimal clinically important difference (MCID) were also recorded. Nine hips were included, and mean follow-up was 36.9 months. Mean preoperative femoral version was 33.0°. Patients underwent 1 or more concomitant procedures, such as labral treatment, capsular plication, acetabuloplasty, or femoroplasty. At latest follow-up, significant improvement was seen for mHHS, NAHS, HOS-SSS, and VAS score. Additionally, rates of meeting the PASS for mHHS, iHOT-12 score, and HOS-SSS were 100%, 88.9%, and 55.6%, respectively. Rates of achieving MCID for mHHS and HOS-SSS were 77.8% and 66.7%, respectively. One hip required revision derotational osteotomy to treat overcorrection, and 3 hips underwent secondary surgery for hardware removal. Concomitant hip arthroscopy and FRO may yield improved outcomes for patients with concurrent intra-articular pathology and excessive femoral anteversion. Considering that no major complications were diagnosed, this procedure is also relatively safe. [Orthopedics. 2021;44(6):e739-e746.].

Modern Suture Anchor Techniques for Gluteus Medius Tear Repair With Concomitant Total Hip Arthroplasty Using the Direct Anterior and Posterior Approaches.

Gluteus medius (GM) tears are currently a well-established source of pain and disability. However, their role in primary total hip arthroplasty (THA) in the setting of osteoarthritis (OA) has been underexamined in the literature. The purpose of this study was to report on short-term patient-reported outcome measurements (PROMs) for patients who underwent concomitant primary THA and GM repair. Data were prospectively collected from September 2011 and June 2017. Inclusion criteria were primary THA along with concomitant GM repair and complete follow-up for the Harris Hip Score, Forgotten Joint Score 12, Veterans RAND 12-item Health Survey both Physical and Mental, 12-item Short Form Survey both Physical and Mental (SF-12 P and SF-12 M), visual analog scale for pain, and patient satisfaction. Patients were excluded if they did not have follow-up. Thirty patients (30 hips) were included. Mean follow-up was 24.2±19.3 months. Twenty-nine (96.7%) patients were female. Mean age was 65.2±7.4 years. Mean body mass index was 31.1±5.9 kg/m2. The posterior approach was used for 16 (53.3%) cases and the anterior approach for the remaining 14 (46.7%). Two (6.7%) patients had a less than 25% tear, 7 (23.3%) had a 25% to 50% tear, 14 (46.7%) had a greater than 50% tear, and 7 (23.3%) had a full-thickness tear. All PROMs except SF-12 M demonstrated significant improvement at latest follow-up. Patients who underwent THA with either the anterior or the posterior approach with concomitant GM repair using modern suture anchor techniques reported favorable PROMs at short-term follow-up. [Orthopedics. 2021;44(5):e653-e660.].

A 5-Year Follow-up of Patients Treated for Full-Thickness Rotator Cuff Tears: A Prospective Cohort Study

Background:The evidence in support of operative versus nonoperative management of rotator cuff tears (RCTs) is limited, based primarily on observational studies of lower scientific merit.Purpose:To (1) compare the efficacy of operative versus nonoperative management of full-thickness RCTs across time and (2) detect variables that predict success within each group.Study Design:Cohort study; Level of evidence, 2.Methods:We included patients with symptomatic full-thickness RCTs who were enrolled in an institutional shoulder registry. Patient enrollment began in 2009 and continued until early 2018. The following outcome measures were collected at baseline, then 6 months, 1 year, and annually up to 5 years postoperatively: Western Ontario Rotator Cuff Index (WORC), American Shoulder and Elbow Surgeons (ASES) score, Veterans RAND 12-Item Health Survey (VR-12) mental and physical component subscales (MCS and PCS, respectively), 100-point Single Assessment Numeric Evaluation (SANE) rating, and 100-point visual analog scale (VAS) for pain and for patient satisfaction. We performed regression models for all outcome variables across all 5 years of follow-up and included the following predictor variables: treatment type (operative vs nonoperative), sex, age, symptom duration, smoking status, diabetes status, injury side, and obesity status.Results:A total of 595 patients were included. Longitudinal mixed-effects regression revealed that patients who received operative treatment did better across time on all outcomes. Women (n = 242; 40.7%) did not fare as well as did men on the ASES, WORC, or VR-12 PCS. Older patients tended to improve less on the VR-12 PCS and more on the VR12-MCS. Patients with longer symptom duration at baseline had better scores across time on the ASES, WORC, VAS for pain, and SANE. Current or recent smokers and patients with diabetes tended to have lower scores on all measures across time. For changes in scores from baseline, patients in the operative group improved to a larger degree out to 3 years compared with those in the nonoperative group.Conclusion:Patients with RCTs tended to improve regardless of whether they received operative or nonoperative treatment, but patients who underwent operative treatment improved faster. There appear to be several predictors of improved and worsened outcomes for patients with RCTs undergoing operative or nonoperative treatment.

Comparison of Teleintegrated Care and Telereferral Care for Treating Complex Psychiatric Disorders in Primary Care

Only one-third of patients with complex psychiatric disorders engage in specialty mental health care, and only one-tenth receive adequate treatment in primary care. Scalable approaches are critically needed to improve access to effective mental health treatments in underserved primary care settings. To compare 2 clinic-to-clinic interactive video approaches to delivering evidence-based mental health treatments to patients in primary care clinics. This pragmatic comparative effectiveness trial used a sequential, multiple-assignment, randomized trial (SMART) design with patient-level randomization. Adult patients treated at 24 primary care clinics without on-site psychiatrists or psychologists from 12 federally qualified health centers in 3 states who screened positive for posttraumatic stress disorder and/or bipolar disorder and who were not already receiving pharmacotherapy from a mental health specialist were recruited from November 16, 2016, to June 30, 2019, and observed for 12 months. Two approaches were compared: (1) telepsychiatry/telepsychology-enhanced referral (TER), where telepsychiatrists and telepsychologists assumed responsibility for treatment, and (2) telepsychiatry collaborative care (TCC), where telepsychiatrists provided consultation to the primary care team. TER included an adaptive intervention (phone-enhanced referral [PER]) for patients not engaging in treatment, which involved telephone outreach and motivational interviewing. Survey questions assessed patient-reported outcomes. The Veterans RAND 12-item Health Survey Mental Component Summary (MCS) score was the primary outcome (range, 0-100). Secondary outcomes included posttraumatic stress disorder symptoms, manic symptoms, depressive symptoms, anxiety symptoms, recovery, and adverse effects. Of 1004 included participants, 701 of 1000 (70.1%) were female, 660 of 994 (66.4%) were White, and the mean (SD) age was 39.4 (12.9) years. Baseline MCS scores were 2 SDs below the US mean; the mean (SD) MCS scores were 39.7 (14.1) and 41.2 (14.2) in the TCC and TER groups, respectively. There was no significant difference in 12-month MCS score between those receiving TCC and TER (β = 1.0; 95% CI, -0.8 to 2.8; P = .28). Patients in both groups experienced large and clinically meaningful improvements from baseline to 12 months (TCC: Cohen d = 0.81; 95% CI, 0.67 to 0.95; TER: Cohen d = 0.90; 95% CI, 0.76 to 1.04). For patients not engaging in TER at 6 months, there was no significant difference in 12-month MCS score between those receiving PER and TER (β = 2.0; 95% CI, -1.7 to 5.7; P = .29). In this comparative effectiveness trial of patients with complex psychiatric disorders randomized to receive TCC or TER, significantly and substantially improved outcomes were observed in both groups. From a health care system perspective, clinical leadership should implement whichever approach is most sustainable. ClinicalTrials.gov Identifier: NCT02738944.

Frequency, severity, and implications of shoulder pain in people with major upper limb amputation who use prostheses: Results of a National Study.

People with upper limb amputation are potentially at increased risk of shoulder pain because they often perform compensatory movements to operate their prostheses and rely more heavily on their nonamputated limb for everyday activities. To describe the frequency, severity, associated factors, and implications of shoulder pain in people with unilateral major upper limb amputation who use prostheses. Cross-sectional, observational design. National recruitment of people living in the community. U.S. veterans and civilians (N=107) with unilateral major upper limb amputation. Not applicable. Shoulder pain (any, ipsilateral and contralateral to amputation), activity performance (Activities Measure for Upper Limb Amputation), health-related quality of life (Veterans RAND 12-Item Health Survey mental component summary [MCS] and physical component summary [PCS]), and disability (Quick Version of the Disabilities of the Arm, Shoulder and Hand Score [QuickDASH]). All participants completed a comprehensive in-person assessment. Participants were 97% male with a mean age of 57.1 years and a mean time since amputation of 23.4 years. The prevalence of any shoulder pain was 30% (15% ipsilateral, 25% contralateral, 10% bilateral). Shoulder pain intensity (0 to 10 scale) was moderate for both ipsilateral (mean 4.9, SD 2.0) and contralateral (mean 4.2, SD 2.0) pain. No significant difference in shoulder pain frequency was observed by amputation level. The prevalence of any shoulder pain was greater in those using a body-powered prosthesis (38% compared to 18% in externally powered users). Each additional year since amputation was associated with an increased likelihood of having contralateral shoulder pain (odds ratio: 1.05, confidence interval: 1.01, 1.10). In linear regression models, those with contralateral shoulder pain had worse PCS (β=-7.07, p=.008) and worse QuickDASH (β=18.25, p < .001) scores. In our sample of predominantly male veterans with major upper limb amputation, shoulder pain was a common condition associated with functional and quality of life implications. Among prosthesis users, the shoulder contralateral to the amputation was at greatest risk, with risk increasing with every year since amputation.

Traditional Versus Digital Media–Based Hand Therapy After Distal Radius Fracture

Distal radius fractures (DRFs) are common injuries with a rising incidence. A substantial portion of the cost of care is attributable to therapy services. Our purpose was to evaluate the effectiveness of a self-directed hand therapy program guided by digital media compared with that of traditional therapy. We conducted a randomized controlled trial in patients aged 18 years or older who underwent open reduction and internal fixation of a DRF with volar plating. Subjects were randomized to traditional hand therapy using a 12-week protocol or an identical protocol presented in digital videos and performed at home. Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores were collected as the primary outcome at 2 weeks (baseline), 6 weeks, and 12 weeks or greater. Pain visual analog scale (VAS) scores, Veterans RAND 12-Item Health Survey (VR-12) scores, wrist and forearm range of motion, wrist circumference, and grip strength were recorded as secondary outcomes. Fifty-one patients were enrolled. Forty-nine patients were included in the analysis-21 in the digital media group and 28 in the traditional group. Both groups demonstrated significant improvements in QuickDASH scores between baseline and 12-week or greater time points. The QuickDASH scores in the digital media group were slightly more improved than those in the traditional group at the 6-week and 12-week or greater time points; however, these differences were not statistically significant. Pain VAS and VR-12 scores were comparable between group differences at each time point. Our digital media program was at least as effective as traditional therapy for patients undergoing volar plating of DRF. These results may help inform the design of future trials investigating the effectiveness of digital media-based hand therapy programs. Therapeutic II.

Treatment of Partial-Thickness Rotator Cuff Tears With a Resorbable Bioinductive Bovine Collagen Implant: 1-Year Results From a Prospective Multicenter Registry

Background:Surgical treatment of partial-thickness rotator cuff tears remains challenging and controversial, with several traditional options including debridement with acromioplasty, transtendon or in situ repair, and take-down and repair. A resorbable bioinductive bovine collagen implant has shown promise as an alternative treatment option for partial-thickness tears.Purpose:Data from a registry were analyzed to further establish that the implant contributes to improved patient-reported outcome (PRO) scores across a large number of patients treated for partial-thickness rotator cuff tears.Study Design:Case series; Level of evidence, 4.Methods:A total of 19 centers in the United States enrolled patients >21 years old with partial-thickness tears of the rotator cuff in a comprehensive prospective multicenter registry. PRO scores were recorded preoperatively and postoperatively at 2 and 6 weeks, 3 and 6 months, and 1 year: American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, Veterans RAND 12-Item Health Survey (physical and mental component scores), and Western Ontario Rotator Cuff scores. Revisions were reported throughout the study.Results:The registry included 272 patients with partial-thickness tears (49 grade 1 tears, 101 grade 2 tears, and 122 grade 3 tears), 241 who underwent isolated bioinductive repair (IBR; collagen implant placed after bursectomy without a traditional rotator cuff repair), and 31 who had take-down and repair with bioinductive augmentation. Patients experienced statistically significant and sustained improvement from baseline for all PRO scores beginning at 3 months. Among patients with grade ≥2 tears, those with take-down and repair had significantly inferior scores at 2 and 6 weeks for most PRO scores as compared with those who underwent IBR, but the difference was no longer significant at 1 year for all but the physical component score of the Veterans RAND 12-Item Health Survey. There were 11 revisions, which occurred at a mean ± SD of 188.7 ± 88.0 days after the index surgery. There were no infections.Conclusion:This registry analysis further establishes across a large data set that this resorbable bioinductive bovine collagen implant improves PROs in all grades of partial-thickness tears, whether used as IBR or in conjunction with take-down and repair. IBR may offer improved early clinical outcomes (≤6 weeks) and comparable outcomes at 1 year when compared with a more invasive “take-down and repair” approach.

Effect of Baseline Mental Health on 1-Year Outcomes After Hip Arthroscopy: A Prospective Cohort Study.

Background:Patient factors, including mental health, sex, and smoking, have been found to be more predictive of preoperative hip pain and function than intra-articular findings during hip arthroscopy for femoroacetabular impingement (FAI); however, little is known about how these factors may influence patients’ postoperative outcomes.Hypothesis:We hypothesized that lower patient-reported mental health scores would be significant risk factors for worse patient-reported outcomes (PROs) 1 year after arthroscopic hip surgery for FAI and that baseline intra-articular pathology would fail to demonstrate an association with outcomes 1 year after FAI surgery.Study Design:Cohort study; Level of evidence, 2.Methods:A prospective cohort of patients undergoing hip arthroscopy for FAI were electronically enrolled. Baseline and 1-year follow-up PROs were collected, including Hip disability and Osteoarthritis Outcome Score for pain (HOOS-Pain), HOOS–Physical Function Short Form (HOOS-PS), and Veterans RAND 12-Item Health Survey–Mental Component Score (VR-12 MCS). Intra-articular operative findings and treatment were documented at the time of surgery. Proportional odds logistic regression models were built for 1-year outcomes (HOOS-Pain, HOOS-PS, and VR-12 MCS). Risk factors included patient characteristics and intraoperative anatomic and pathologic findings.Results:Overall, 494 patients underwent hip arthroscopy for FAI, and 385 (78%) were evaluated at 1 year with at least 1 PRO. The median patient age was 33 years, mean body mass index was 25.5 kg/m2, and 72% were female. Multivariable analysis demonstrated that better baseline HOOS-Pain, HOOS-PS, and VR-12 MCS were significantly associated with improvement in the 1-year scores for each PRO. Higher VR-12 MCS was significantly associated with better 1-year HOOS-Pain and HOOS-PS, while current and former smokers had worse 1-year outcomes than those who never smoked. In ranking each variable’s relative importance, baseline HOOS-Pain and HOOS-PS and baseline VR-12 MCS were identified as the strongest predictors of 1-year HOOS-Pain and HOOS-PS in our multivariable model.Conclusion:During hip arthroscopy for FAI, patient factors, including baseline hip pain and function, mental health, and smoking, were independently associated with 1-year PROs of hip pain and function, while intra-articular pathology such as the presence of labral tear and its treatment, tear size, tear location, and anchors placed were not independently associated.

Patient Resilience Has Moderate Correlation With Functional Outcomes, but Not Satisfaction, After Primary Unilateral Total Knee Arthroplasty.

BackgroundAs many as 20% of patients who undergo total knee arthroplasty (TKA) are dissatisfied. Psychological factors have been shown to play a role in outcomes after TKA. The purpose of this study was to investigate the impact of patient resilience on functional outcomes and satisfaction after primary unilateral TKA.MethodsEighty-six patients who underwent primary unilateral TKA by a single surgeon were studied. Primary outcomes were the Brief Resilience Scale (BRS), mental health component of the Veterans Rand 12-Item Health Survey (VR-12 MCS), Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, and New Knee Society Score. Correlations between BRS and dependent variables were found by using Spearmen’s Rho Correlation testing. Unadjusted and adjusted regressions were run using the delta values as the dependent outcome and the BRS score as the main independent value, with data presented as an estimate of 95% confidence interval P value.ResultsResilience significantly correlated with male sex (P = .031), preoperative VR-12 MCS scores (P = .013), and postoperative VR-12 MCS scores (P < .001). BRS had moderate correlation with postoperative Knee Society Scores (KSS) Functional Activity Scores, as this approached, but did not achieve statistical significance (P = .062). There was no correlation between BRS and postoperative KSS Patient Expectations score, KSS Patient Satisfaction score, or total postoperative opioid usage.ConclusionsPrimary TKA patients with greater resilience are more likely to be male and have better mental health characteristics than those with lower resilience. Patients with greater resilience also tended to have improved knee function after TKA, although this was not statistically significant. Resiliency did not correlate with postoperative opioid consumption or patient satisfaction after TKA.

Can We Predict Unplanned Intensive Care Unit Admission in Hip and Knee Arthroplasty?

AbstractPreoperative risk stratification remains important for both patient safety and cost-effective allocation of resources in total joint arthroplasty. Limited literature exists investigating risk factors for unplanned intensive care unit (ICU) admission following arthroplasty. Therefore, the purpose of this study was to assess a broader spectrum of factors that may increase the risk of ICU admission across multiple surgical settings. We retrospectively reviewed 18,169 patients who underwent a hip (40.7%) or knee (59.3%) arthroplasty procedure (primary: n = 13,384, 90%; revision: n = 1,485, 10%) between August 1, 2015, and January 31, 2019, across nine sites at a single institution. Patient demographics, laboratory data, surgical parameters, and preoperative scores on the Hip Disability and Osteoarthritis Outcome Score (HOOS) or Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Veterans RAND 12-Item Health Survey (VR-12) were recorded. A univariate analysis was conducted to identify differences between patients who required an ICU admission and those with no ICU involvement. Logistic regression was then used to generate predicted risk of ICU Involvement. A total of 147 patients (0.99%) required an ICU admission. Increasing age, higher Charlson's comorbidity index, American Society of Anesthesiologists (ASA) class 3 or greater, elevated blood urea nitrogen (BUN), elevated creatinine, decreased preoperative hemoglobin level, general anesthesia, surgical setting, revision procedure, and lower baseline scores on the KOOS Quality of Life (QOL) subscale (17 vs. 22.5, p = 0.032), VR-12 physical component score (PCS; 24.4 vs 27.1, p = 0.001), and VR-12 mental component score (MCS; 45.9 vs. 49.6, p = 0.003) were associated with a statistically significant increase in the risk of ICU admission. As performance of arthroplasty shifts in both the setting of care and the complexity of patients, identifying patients most at risk of requiring higher acuity of care is important. Preoperative assessment of comorbidities, kidney function, surgical setting, KOOS QOL subscale score, and VR-12 scores may provide guidance for the improvement of value-based care pathways.

Patient Health Questionnaire-9 Is a Valid Assessment for Depression in Minimally Invasive Lumbar Discectomy.

ObjectiveThe Patient Health Questionnaire-9 (PHQ-9) is a screening tool for evaluating depressive symptoms. Research is scarce regarding the validity and correlation of PHQ-9 scores with other patient-reported outcomes of mental health after minimally invasive lumbar discectomy (MIS LD). We aim to validate PHQ-9 as a metric for assessing mental health in MIS LD patients. MethodsA database was retrospectively reviewed for patients who underwent elective, single-level MIS LD. Patients were excluded if they had incomplete preoperative PHQ-9, 12-item Short Form Health Survey (SF-12), or Veterans RAND 12-item health survey (VR-12). Survey scores were collected preoperatively and postoperatively through 1 year. Mean scores were used to calculate postoperative improvement from preoperative scores. Correlation of PHQ-9 with SF-12 mental composite score (MCS) and VR-12 MCS scores was also calculated. Correlation strength was assessed by the following categories: 0.1 ≤ |r| < 0.3 = low; 0.3 ≤ |r| < 0.5 = moderate; |r| ≥ 0.5 = strong. ResultsA total of 239 patients underwent single-level MIS LD. PHQ-9, VR-12 MCS, and SF-12 MCS all demonstrated statistically significant increases from preoperative scores at all postoperative timepoints (p ≤ 0.001). SF-12 MCS and VR-12 MCS were each observed to have strong and significant correlations with PHQ-9 at all timepoints when evaluated with both Pearson correlation coefficients and partial correlation coefficients. ConclusionWe observed that PHQ-9, SF-12 MCS and VR-12 MCS all significantly improve following lumbar discectomy and that PHQ-9 scores strongly correlated with these previously established measures. Our results substantiate evidence from other surgical fields that PHQ-9 scores are a valid tool to evaluate pre- and postsurgical depressive symptoms.

Physical and Psychological Recovery Following Toxic Epidermal Necrolysis: A Patient Survey.

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are acute, life-threatening diseases that cause sloughing of the skin and mucous membranes. Despite improved survival rates, few studies focus on long-term outcomes. We conducted a single-center review of all patients with SJS/TEN admitted from January 2008 to 2014. SJS/TEN survivors were invited to participate in the validated Veterans RAND 12-Item Health Survey (VR-12) to assess health-related quality of life using a mental health composite score and physical health component score (PCS). The sample was compared to U.S. norms using one-sample two-tailed t tests. A second questionnaire addressed potential long-term medical complications related to SJS/TEN. Of 81 treated subjects, 24 (30%) long-term survivors responded. Participants identified cutaneous sequelae most frequently (79%), followed by nail problems (70%), oral (62%), and ocular (58%) sequalae. Thirty-eight percent rated their quality of life to be "unchanged" to "much better" since their episode of SJS/TEN. The average PCS was lower than U.S. population norms (mean: 36 vs 50, P = .006), indicating persistent physical sequelae from SJS/TEN. These results suggest that SJS/TEN survivors continue to suffer from long-term complications that impair their quality of life and warrant ongoing follow-up by a multidisciplinary care team.

Testing the Feasibility of Sensor-Based Home Health Monitoring (TEC4Home) to Support the Convalescence of Patients With Heart Failure: Pre-Post Study.

BackgroundPatients with heart failure (HF) can be affected by disabling symptoms and low quality of life. Furthermore, they may frequently need to visit the emergency department or be hospitalized due to their condition deteriorating. Home telemonitoring can play a role in tracking symptoms, reducing hospital visits, and improving quality of life.ObjectiveOur objective was to conduct a feasibility study of a home health monitoring (HHM) solution for patients with HF in British Columbia, Canada, to prepare for conducting a randomized controlled trial.MethodsPatients with HF were recruited from 3 urban hospitals and provided with HHM technology for 60 days of monitoring postdischarge. Participants were asked to monitor their weight, blood pressure, and heart rate and to answer symptomology questions via Bluetooth sensors and a tablet computer each day. A monitoring nurse received this data and monitored the patient’s condition. In our evaluation, the primary outcome was the combination of unscheduled emergency department revisits of discharged participants or death within 90 days. Secondary outcomes included 90-day hospital readmissions, patient quality of life (as measured by Veterans Rand 12-Item Health Survey and Kansas City Cardiomyopathy Scale), self-efficacy (as measured by European Heart Failure Self-Care Behaviour Scale 9), end-user experience, and health system cost-effectiveness including cost reduction and hospital bed capacity. In this feasibility study, we also tested the recruitment strategy, clinical protocols, evaluation framework, and data collection methods.ResultsSeventy participants were enrolled into this trial. Participant engagement to monitoring was measured at 94% (N=70; ie, data submitted 56/60 days on average). Our evaluation framework allowed us to collect sound data, which also showed encouraging trends: a 79% reduction of emergency department revisits post monitoring, an 87% reduction in hospital readmissions, and a 60% reduction in the median hospital length of stay (n=36). Cost of hospitalization for participants decreased by 71%, and emergency department visit costs decreased by 58% (n=30). Overall health system costs for our participants showed a 56% reduction post monitoring (n=30). HF-specific quality of life (Kansas City Cardiomyopathy Scale) scores showed a significant increase of 101% (n=35) post monitoring (P<.001). General quality of life (Veterans Rand 12-Item Health Survey) improved by 19% (n=35) on the mental component score (P<.001) and 19% (n=35) on the physical component score (P=.02). Self-efficacy improved by 6% (n=35). Interviews with participants revealed that they were satisfied overall with the monitoring program and its usability, and participants reported being more engaged, educated, and involved in their self-management.ConclusionsResults from this small-sample feasibility study suggested that our HHM intervention can be beneficial in supporting patients post discharge. Additionally, key insights from the trial allowed us to refine our methods and procedures, such as shifting our recruitment methods to in-patient wards and increasing our scope of data collection. Although these findings are promising, a more rigorous trial design is required to test the true efficacy of the intervention. The results from this feasibility trial will inform our next step as we proceed with a randomized controlled trial across British Columbia.Trial RegistrationClinicalTrials.gov NCT03439384; https://clinicaltrials.gov/ct2/show/NCT03439384

Short-Term Clinical and Return-to-Work Outcomes After Arthroscopic Suprapectoral Onlay Biceps Tenodesis With a Single Suture Anchor

PurposeTo describe short-term outcomes of arthroscopic suprapectoral onlay biceps tenodesis using a single all-suture anchor with respect to validated outcome measures, return to work, objective strength and motion data, and biceps-specific testing.MethodsThis study describes a consecutive series of patients undergoing arthroscopic suprapectoral onlay biceps tenodesis performed by a single surgeon from January to December 2017. Patients were evaluated preoperatively and postoperatively with the American Shoulder and Elbow Surgeons questionnaire, visual analog scale, Single Assessment Numeric Evaluation, Veterans RAND 12-Item Health Survey, and 12-Item Short Form survey, and return-to-work survey. Postoperative strength, range of motion, and biceps-specific testing was also performed.ResultsThis study included 50 patients (26 men and 24 women), with an average age (± standard deviation) of 50.1 ± 10.9 years and average final follow-up of 21.3 ± 8.5 months. Among employed patients, 32 (71.1%) returned to work at an average of 4.6 ± 2.3 months. Light-duty workers returned to work at a significantly greater rate (85.7% vs 33.3%, P = .016) and in less time (2.6 ± 2.0 months vs 6.8 ± 4.2 months) than heavy-duty workers. No differences were found between operative and nonoperative sides in the biceps apex distance (P = .636) or range of motion in elbow flexion and extension (P > .9 for both), supination (P = .192), or pronation (P = .343) postoperatively. Strength in elbow flexion (P = .002), as well as shoulder forward elevation (P < .001) and external rotation (P < .001), increased postoperatively. Significant patient-reported improvements were noted in the American Shoulder and Elbow Surgeons score, visual analog scale pain score, Single Assessment Numeric Evaluation score, Constant-Murley score, and Veterans RAND 12-Item Health Survey and 12-Item Short Form physical component scores (P ≤ .001 for all). A postoperative Popeye deformity developed in 5 patients (10%).ConclusionsArthroscopic suprapectoral onlay biceps tenodesis with a single all-suture anchor can provide overall excellent clinical outcomes regarding strength, motion, and validated patient-reported outcome questionnaires. Return to occupational activities may be less predictable and more prolonged for heavy laborers. A small number of patients may experience cosmetic deformity postoperatively.Level of EvidenceLevel IV, therapeutic case series.