Impact of smoking on patient-reported outcome measures after arthroscopic rotator cuff repair: a 2-year comparative cohort study.

BACKGROUND AND HYPOTHESIS: Smoking is a well-established risk factor for tendon healing. The purpose of this study was to evaluate the differences in patient-reported outcome measures between smokers and nonsmokers who have undergone arthroscopic rotator cuff repair. It was hypothesized that smokers would have worse self-reported outcomes at 1 and 2 years postoperatively. METHODS: A total of 560 consecutive patients who underwent arthroscopic rotator cuff repair were divided into 2 groups: group I (smokers) n = 25 and group II (nonsmokers) n = 535. All participants were administered preoperative and postoperative surveys consisting of the following outcome-measuring tools: (i) visual analog scale, (ii) Veterans Rand 12-Item Health Survey, (iii) American Shoulder and Elbow Surgeons shoulder score, (iv) standard preoperative form consisting of 4 questions regarding their expectations of recovery, (v) Single Assessment Numeric Evaluation shoulder score, and (vi) Simple Shoulder Test. RESULTS: At 1 and 2 years postoperative, nonsmokers reported statistically significant differences in Veterans Rand 12-Item Health Survey mental scores (56.2 vs. 51.9, P = .0162 and 56.3 vs. 49.5, P = .0004, respectively). American Shoulder and Elbow Surgeons Shoulder scores showed no differences until the 2-year mark, at which time nonsmokers reported higher scores than smokers (87.9 vs. 79.0, P = .0212). Single Assessment Numeric Evaluation scores also remained similar up until 2-year follow-up, at which time nonsmokers reported statistically significant improvement (80.0 vs. 68.5, P = .0339). Nonsmokers reported higher Simple Shoulder Test scores at baseline and at 2-year follow-up (43.3 vs. 37.0, P = .0417 and 83.7 vs. 68.1, P = .0046, respectively). CONCLUSION: At 2 years postoperatively, nonsmokers had significantly higher patient-reported outcome measure scores than smokers. In elective surgery, smoking status should be considered as a risk factor for poorer patient-reported outcomes after arthroscopic rotator cuff repair. However, smokers continue to report a clinical benefit at 2 years postoperatively.

Long-term Outcomes of Silastic Arthroplasty of the Thumb Metacarpophalangeal Joint.

Background: Silastic metacarpophalangeal arthroplasty (SMPA) has proven to be a durable option for end-stage arthritis in the non-thumb digits, while fusion has been the mainstay procedure for the thumb metacarpophalangeal joint (MP). Few studies exist to comment on the viability of thumb MP arthroplasty. This study reports both survival and objective outcomes following SMPA of the thumb. Methods: In an institutional review board-approved retrospective study, we identified 18 patients who underwent thumb SMPA at a tertiary academic center by 3 board-certified hand surgeons. Primary outcome measures were implant survival and post-operative complications. Secondary outcomes measures were quick Disabilities of the Arm, Shoulder, and Hand (quickDASH) scores, brief Michigan Hand Questionnaire (bMHQ), and postoperative pain as rated by the numerical rating scale. Results: Mean quickDASH and bMHQ scores at final follow-up were 35.6 and 70.6, respectively. The most common short-term complication was clinical deformity, followed by instability. The sole long-term complication was an implant dislocation in a previously asymptomatic patient. All patients reported reduction in pain. Three patients were indicated for revision surgery, 2 for persistent instability, and 1 for implant dislocation. Primary survivorship was 83% at mean follow-up of 5.8 years. Conclusions: Thumb SMPA is a viable option for end-stage arthritis. Pain relief in our series was unanimous. Among those that reported persistent symptoms or required revision, a majority had one or more key preoperative risk factors for failure as currently reported in literature. Larger, prospective series are needed to prove superior longevity and functional outcomes of thumb SMPA versus fusion.

Outcomes of Mini-Open Carpal Tunnel Release in Patients With Unrecordable Preoperative Nerve Conduction Potentials at a Minimum of 5 Years.

Background: The aim of this study is to assess the outcomes of carpal tunnel release (CTR) in a cohort of patients with preoperatively unrecordable median nerve sensory and motor potentials in comparison with historical controls at minimum 5-year follow-up. Methods: We retrospectively identified 1297 patients who underwent CTR at a tertiary care referral center from July 2008 to June 2013. After exclusion criteria and review of available preoperative nerve conduction studies, 24 patients who underwent CTR with preoperative unrecordable sensory and motor nerve potentials were identified. Fifteen living, mentally capable patients were contacted by telephone for follow-up. Our primary outcome measure was the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ). Secondary outcome measures included Disabilities of the Arm, Shoulder, and Hand (DASH) score, pain on a 0 to 10 Likert scale, and satisfaction on a 0 to 10 Likert scale. Results: Our response rate was 80% (12 out of 15) of eligible patients. Mean follow-up was 6.9 years in our study (range, 5.4-9.5 years). The mean BCTQ symptom score was 1.4, and the mean BCTQ functional score was 1.8. Mean DASH score was 15.2. On average, patient-reported pain was 0.3 and satisfaction was 8.3. No difference was found in outcomes of CTR in patients with end-stage carpal tunnel syndrome compared with historical means. Conclusions: Patients with end-stage carpal tunnel syndrome do not have worse long-term patient-reported outcomes after CTR compared with the general population. Unrecordable nerve potentials are not a contraindication for CTR.

Prevalence of idiopathically elevated ESR and CRP in patients undergoing primary total knee arthroplasty as a function of body mass index.

BACKGROUND: Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are commonly used inflammatory markers utilized to aid in the diagnosis of periprosthetic infection (PJI). Patients with obesity, however, are known to have elevated baseline levels of these inflammatory markers. Therefore, this retrospective study aimed to determine the relationship between elevated ESR and CRP and body mass index (BMI) in patients undergoing total knee arthroplasty (TKA). In doing so, physicians can better determine whether BMI should be taken into account when evaluating the prognostic value of elevated preoperative ESR and CRP levels for risk of PJI in primary TKA patients. METHODS: This is a retrospective case series of 181 patients who had undergone primary TKA at a single institution. Patients undergoing primary unilateral TKA were eligible unless they had undergone previous TKA, contralateral knee symptoms, or elevated white blood cell (WBC) count. A linear regression model was utilized to demonstrate the relationship between proportions of patients with elevated biomarker values and categories of BMI. Analysis of variance and independent two-sample t-tests were utilized to assess differences in mean ESR, CRP, and WBC levels between the "healthy patients" and "patients with comorbidities" subgroups within each BMI category. RESULTS: Eligible patients (n = 181) were stratified by BMI category. Elevated ESR was associated significantly with BMI (ESR: r2 = 0.89, P < 0.001) unlike elevated CRP (r2 = 0.82, P = 0.133) and WBC count (r2 = .01; P = .626). No statistically significant differences in ESR values and WBC count between the "healthy patients" versus "patients with comorbidities" were demonstrated within any BMI category. In patients of normal weight (BMI 20-25 kg/m2), "healthy patients" had a statistically significantly higher mean CRP level than "patients with comorbidities" (1.73 mg/L vs. 0.70 mg/L, P < 0.001). There were no other statistically significant differences in mean CRP levels by health status. CONCLUSION: Caution is advised when utilizing ESR and CRP to diagnose periprosthetic joint infection without considering BMI given that increasing preoperative levels of ESR and CRP are correlated with higher BMI.

Thumb Metacarpophalangeal Joint Arthritis.

Arthritis of the thumb metacarpophalangeal joint can be debilitating whether in isolation or in conjunction with degenerative disease at the adjacent joints. Despite its crucial role in fluid and dexterous motion of the thumb axis, little is known about the isolated incidence of pathology at this joint. Etiologies include primary, posttraumatic, and inflammatory arthritis. For early, isolated degenerative disease, arthroscopic synovectomy has been shown to yield satisfactory results. For more advanced disease, fusion is the benchmark. The literature suggests that increased flexion angles may mitigate development of trapeziometacarpal arthritis. In case of advanced arthropathy of the entire thumb axis, arthroplasty is a viable option to reduce pain, preserve motion, and thus limit progression of adjacent joint disease. Special considerations should be given to the rheumatoid thumb because a select combination of treatments for each deformity is thought to best address the unique pathomechanics.

Descending Geniculate Artery Pseudoaneurysm Following Tibial Plateau Fracture.

Pseudoaneurysms are uncommon in patients with trauma, but can cause diagnostic difficulty and result in significant morbidity. Etiologies range from penetrating and nonpenetrating trauma to operative injury during fracture fixation, arthroscopy, total joint arthroplasty, and hardware loosening and removal. Pseudoaneurysms can conspicuously present as a pulsatile mass with an audible bruit, or as a subtly expanding hematoma. In either case, the complications can be serious if diagnosed late. The authors report a case of a pseudoaneurysm arising from the descending geniculate artery following a tibial plateau fracture. This was suspected following a slowly expanding hematoma and persistent anemia refractory to transfusion. Computed tomography angiography was used for confirmation. Successful treatment was accomplished with embolization, surgical evacuation of the hematoma, delayed skin grafting, and fracture fixation. The postoperative outcome was satisfactory, with complete wound healing, functional but decreased range of motion, normal perfusion distal to the injury, and the sole report of mild intermittent knee pain. [Orthopedics. 2017; 40(1):e188-e191.].

Osteoporosis Diagnosis and Management in Long-Term Care Facility.

BACKGROUND: Contemporary estimates of the prevalence of diagnosed osteoporosis among long-term care facility residents are limited. METHODS: This chart review collected data between April 1, 2012 and August 31, 2013 for adult (age ≥ 30 years) residents of 11 long-term care facilities affiliated with the Louisiana State University Health Sciences Center in the New Orleans metropolitan area. Data (demographics; comorbidities; osteoporosis diagnosis, risk factors, diagnostic assessments, treatments; fracture history; fall risk; activities of daily living) were summarized. Data for residents with and without diagnosed osteoporosis were compared using χ tests and t tests. RESULTS: The study included 746 residents (69% women, mean [SD] age: 76.3 [13.9] years, median length of stay approximately 18.5 months). An osteoporosis diagnosis was recorded for 132 residents (18%), 30% of whom received a pharmacologic osteoporosis therapy. Fewer than 2% of residents had bone mineral density assessments; 10% had previous fracture. Calcium and vitamin D use was more prevalent in residents with diagnosed osteoporosis compared with other residents (calcium: 49% versus 12%, vitamin D: 52% versus 28%; both P < 0.001). Over half (304/545) of assessed residents had a high fall risk. Activities of daily living were similarly limited regardless of osteoporosis status. CONCLUSIONS: The prevalence of diagnosed osteoporosis was higher than previously reported for long-term care residents, but lower than epidemiologic estimates of osteoporosis prevalence for the noninstitutional U.S. POPULATION: In our sample, osteoporosis diagnostic testing was rare and treatment rates were low. Our results suggest that osteoporosis may be underdiagnosed and undertreated in long-term care settings.

Antiretroviral therapy at the end of life: the experience of an academic HIV clinic.

INTRODUCTION: There are no guidelines regarding the discontinuation of antiretroviral therapy at the end of life. METHODS: We retrospectively reviewed our databases and identified patients with HIV/AIDS who died over the last 12 months in our HIV clinic. RESULTS: A total of 41 patients from our HIV clinic died in a period of 12 months. Seventy-three percent of the patients were on antiretroviral therapy during the last clinic visit. During the last 3 months of life, 32% (13 of 41) were off antiretroviral therapy, with 77% (10 of 13) of them having intermittent therapy due to noncompliance. The remaining 23% (3 of 13) decided to stop antiretroviral therapy after discussion among families, patients, and providers. CONCLUSION: Discussions among providers, patients, and families are encouraged to establish goals of care and role of antiretrovirals during the last months of life.

An analysis of chronic kidney disease risk factors in a Louisiana nursing home population: a cross-sectional study.

BACKGROUND: Chronic Kidney Disease (CKD) and its progression are associated with multiple risk factors. CKD is prevalent in nursing homes residents, but factors related to CKD in this setting have not been defined. METHODS: A cross-sectional study was conducted (n=103). Data was abstracted using standardized forms and analyzed (SAS 9.2). Chi square and t-test statistics were used to compare proportions and means; correlation coefficients were used to describe associations. Logistic models were fit to the data to determine multivariate associations. Modification of Diet in Renal Disease (MDRD) formula was used to estimate GFR. CKD was defined according to established standards. A cutoff point of 60 was chosen for further analysis. RESULTS: Twenty-three percent of subjects had CKD. Mean age for eGFR <60 was 70.8 +/- 13 and for eGFR >60 was 61.7 +/-14. Frequent co-morbidities were hypertension (75%), GERD (40%), obesity (39%), dyslipidemia (35%), depression (34%), anemia (32%), and diabetes (32%). CONCLUSIONS: Our population is unique in terms of its age and reasons for nursing home admission. Factors associated with CKD in our study include age >65 years old, being male, having a positive history of cardiovascular disease (including congestive heart failure and coronary artery disease,) anemia, polypharmacy, and being obese (BMI >30). Further analysis showed that age and anemia are the strongest factors associated with CKD in our population. Management targeted at CKD risk factor reduction may play a vital role in controlling the magnitude of this disease. Prospective studies to investigate the relationship between gender, a BMI greater than 30, cardiovascular disease, and CKD and its complications are warranted.

Falls in HIV-infected patients: a geriatric syndrome in a susceptible population.

BACKGROUND: Falls is a common geriatric syndrome that has not been well characterized in HIV-infected populations. METHODS: We retrospectively reviewed our database and identified patients who fell over the last 12 months. RESULTS: Thirty-two patients were identified (incidence rate of 16 × 1000 patients per year). Twenty-five percent were female and 75% male. Sixty-seven percent were African American with 33% Caucasians. Average age was 48.19, number of years with HIV infection on average was 9.38 years, mean CD4 count 347.2 cell/mm(3), mean HIV viral load was 31 379 copies/mL. The average number of medications was 8.7 with a mean of 3.48 comorbidities. The mean vitamin D level was 27.20. Sixty-two percent of patients were compliant with antiretroviral therapy. Univariate and multivariate analysis showed that number of medications (< .005 medications; P < .005), more than 3 comorbidities (P < .005), and noncompliance (P < .001) were related to falls in this population. CONCLUSION: Falls is a common geriatric syndrome. Associated risk factors in our cohort included number of medications, more than 3 comorbidities, and noncompliance. Larger studies are needed to properly characterize this geriatric syndrome in HIV-infected patients. As HIV-infected populations age, a shift into a more comprehensive geriatrics care including fall risk evaluation may be needed.

Non-AIDS-defining cancers in New Orleans.

BACKGROUND: Non-AIDS-defining cancers in HIV-infected patients in the highly active antiretroviral therapy era have increased. To our knowledge a comprehensive review of non-AIDS-related malignancies in New Orleans has not yet been conducted. METHODS: Databases from main institutions in New Orleans were queried retrospectively for the years 2001 to 2011. The International Classification of Diseases, Ninth Revision codes were used to search for HIV infection and cancer comorbidity. RESULTS: A total of 16 patients were diagnosed with lung cancer (mean age 50 years) with 81% of the patients presenting with advanced stages. In all, 20 (mean age 47 years) were diagnosed with anal cancer, and 35% presented in late stages. In all, 14 patients (mean age 42 years) were diagnosed with Hodgkin Lymphoma, and 64% were diagnosed at late stage. A total of 5 women (mean age 44 years) were diagnosed with breast cancer with 40% of them presenting at late stage. CONCLUSION: Malignancies were diagnosed at late stages in the majority of the cases, presented with worse outcomes, and had higher recurrence rates. The role of HIV and other viruses (Epstein Barr virus, human papillomavirus) and the potential mechanisms or pathways of oncogene activation also need to be clarified.

Management of elderly and frail elderly cancer patients: the importance of comprehensive geriatrics assessment and the need for guidelines.

OBJECTIVES: Management of elderly and frail patients with cancer is complex and requires a multidisciplinary approach. This article reviews and discusses the current literature that evaluates the relevance of comprehensive geriatrics assessment (CGA) and other evaluation tools in the detection of this vulnerable patient population. METHODS: A literature search of articles in English, Spanish and Portuguese was conducted in PubMed through September 2011. RESULTS: There is lack of detailed information concerning the efficacy, tolerability and toxicity of cancer therapies in senior adults, although the literature indicates that there is a trend toward including elderly patients and their outcome. Recent guidelines advocate a careful patient selection through a CGA. For vulnerable (pre-frail) and frail elderly cancer patients, there is no consensus in relation to selection and type of treatments. CGA has been advocated as the gold standard for evaluation of elderly patients, but thorough evaluation of vulnerable and frail patients has not been undertaken. A tool to evaluate vulnerable elderly patients to predict treatment outcomes is also needed. DISCUSSION: The adoption of the CGA in oncology practice has been slow because of the difficulties with practicality and objectivity. A shorter reliable tool for rapid and complete assessment is needed. Inclusion of frail elderly patients in treatment trials is recommended. New treatment approaches for frail elderly cancer patients need to be further investigated. Some studies that used serum markers of frailty found that even in the absence of clinical signs, some elderly patients might be already vulnerable. A potential cancer frailty index also needs further investigation.

Differences in outcomes between elderly and nonelderly breast cancer patients in Louisiana.

INTRODUCTION: Elderly breast cancer patients are diagnosed with a higher stage of disease. They are also found to undergo less surgery, receive more frequently hormonal treatment and have decreased relative survival. The interest of this study was to examine the differences in treatment and survival between elderly versus young (>65 versus <65) patients in Louisiana. METHODS: The SEER database was searched, and all cases of female breast cancer in the state of Louisiana between 2000 and 2008 were analyzed. Data were stratified by age group and year of occurrence. The SEER definitions for breast cancer, surgery, chemotherapy, elderly populations, young populations, radiation therapy and breast conservative surgery were applied. RESULTS: The state prevalence of localized breast cancer is lower compared with the national rate (128.5 versus 144, P < 0.001). The rate of regional breast disease is much higher in Louisiana patients than national average rate (69.7 versus 57.9, P < 0.001). There is no difference in disseminated disease. The elderly group was offered less surgery compared with the young group (11.39% versus 6.68%, P < 0.005). The elderly group received more general radiation interventions than the young group (65.97% versus 53.86%, P < 0.005). Mortality rates for the elderly group were higher in Louisiana compared with the national average. This difference was more remarkable in the >85 age group (127.8 versus 118.5, P < 0.001). CONCLUSIONS: Differences between young and elderly breast cancer patients were observed. Mortality is higher among elderly breast cancer patients in Louisiana compared with the national average. Further studies are needed to review these differences.

Frailty syndrome in geriatric medicine.

Frailty syndrome is frequently encountered in elderly populations. Frailty has been defined as a geriatric syndrome of increased vulnerability to environmental factors. Although knowledge of this syndrome continues to develop, there are still many areas of uncertainty. The pathophysiological pathways, role of biomarkers in the early identification of this syndrome and best management strategies are still under investigation. This study is a literature review of articles published on frailty syndrome in English, French and Spanish. Frailty and aging are similar processes with some differences. Multiple pathophysiological models of frailty have been studied. Factors associated with frailty include hormonal adjustments, sarcopenia and vitamin deficiencies among others. Biomarkers have been studied, but they are not specific. Phenotypes have been developed, but early recognition and prevention of this syndrome are still difficult. In conclusion, early recognition of this syndrome is of paramount importance. Preventative strategies need to be studied. The role of specific biomarkers in early detection of frailty needs to be defined. Clinical trials are needed to find better interventions for this syndrome.

Theories and mechanisms of aging.

This article discusses various theories of aging and their relative plausibility related to the human aging process. Structural and physiologic changes of aging are discussed in detail by organ system. Each of the organ systems is discussed when applicable to the various theories of aging. Normal versus abnormal aging is discussed in the context of specific aging processes, with atypical presentations of disease and general links to life expectancy. Life expectancy and lifespan are discussed in the context of advances in medical science and the potential ultimate link to human life span.

Characteristics of Frail Patients in a Geriatric-HIV Program: The Experience of an Urban Academic Center at One Year Follow-Up.

INTRODUCTION: Frailty syndrome has not been explored in depth in elderly HIV-infected patients. METHODS: As of December 2009, a total of 60 patients (out of 160 patients > 60 years) were screened and 20 patients were transferred to our newly created Geriatrics-HIV program. We divided this group of already ''frail patients'' in three different subgroups; the mildly, moderately and the very frail groups based on the number of domains failed during the initial geriatrics screening. RESULTS: The percentages of mildly, moderately, and severely frail elderly patients in our cohort were 20% 50% and 30% respectively. The most common comorbidities found were HTN (60%), and history of AIDS-related opportunistic infections (40%). Smoking was highly prevalent in all groups. The average number of medications used per patient was 8.1 with 65% of patients being compliant with their regimens. DISCUSSION: We found that cognitive impairment, presence of comorbidities, high number of medications used, and past history of any opportunistic infection are factors prevalent in severely frail patients infected with HIV in our cohort. The significance of these factors in development and progression of frailty syndrome in HIV-positive patients needs to be elucidated.

Palliative care program for human immunodeficiency virus-infected patients: rebuilding of an academic urban program.

BACKGROUND: palliative care is extremely important for human immunodeficiency virus (HIV)-infected clientele. The impact of HIV infection is significant in the city of New Orleans. As of September 2009, a cumulative total of 29 548 HIV/acquired immunodeficiency syndrome (AIDS) cases and 12 267 HIV-related deaths were reported in Louisiana. METHODS: retrospective review of charts of patients enrolled in our palliative care program. RESULTS: as of September 2009, there were around 1800 active patients in our HIV outpatient clinic. A total of 5 (22%) patients had multidrug-resistant AIDS infection. Three (13%) referred patients had AIDS dementia. Progressive multifocal leukoencephalopathy (PML) and advanced HIV nephropathy were also reasons for referral (13% and 4% of referred patients, respectively). Around 9% of patients had advanced liver cancer with metastases. In all, 22% of patients had rapidly deteriorating functional status. The rest of the patients (26%) complained of cancer-related nausea and vomiting and progressive and nonresponsive weight loss. In terms of psychosocial assessment, the majority of referred patients had problems in areas such as social functioning, mood swings, unstable moods, problems with controlling temper, outbursts of anger, violence, and disturbing or unreal thoughts and beliefs. CONCLUSIONS: palliative care is extremely important in the care of patients with HIV/AIDS. More research is needed to elaborate on best palliative care practices in the care of HIV-infected patients. Interesting to note is that there is significant proportion of patients with mental issues (substance abuse, psychiatric problems, depression, and despair) for which better resources are needed. Integration of services among clinical, mental, and palliative care providers might be needed to better serve this population.

A dedicated screening program for geriatric HIV-infected patients integrating HIV and geriatric care.

BACKGROUND: Clinicians caring for HIV-infected patients >60 years old encounter multiple clinical challenges. The use of a functional geriatrics screening for detection of significant comorbidities is important in this population. METHODS: The geriatrics screening evaluated functional capabilities, depression, cognitive dysfunction, nutrition, mobility, medicines used, and interactions. RESULTS: As of July 2009, 57 patients were screened (average age 62.6, 39 males and 18 females). A total of 17 patients (9 males and 8 females) were referred to the geriatrics/HIV program because of identified problems in multiple domains: 10 with cognitive dysfunction, 8 with problems in basic or instrumental activities of daily living, 6 with nutritional issues, 5 with depression, 5 with mobility problems, 4 with visual issues, and 2 with hearing difficulties. The average age was 62.9. Median CD4 count and viral load were 285 (15-714) cells/mm(3) and 30 505 copies/mL (0-407 697), respectively. CONCLUSIONS: The functional yearly screening of patients >60 years with HIV needs to be part of regular care of patients infected with HIV as multiple functional problems can be diagnosed and addressed.