A Rare Case of Acute Methotrexate Toxicity Leading to Bone Marrow Suppression.

Methotrexate is a first-line disease modifying antirheumatic drug used for the treatment of inflammatory arthritis. Bone marrow suppression is a common adverse reaction of methotrexate following its long-term use. However, low dose methotrexate is rarely associated with life-threatening bone marrow suppression. This case represents an atypical presentation of acute bone marrow suppression shortly after initiating treatment with low-dose methotrexate. A 76-year-old male patient presented with oral ulcers, poor oral intake, and acute kidney injury within 3 weeks of initiating 15 mg weekly of methotrexate for seronegative rheumatoid arthritis. Complete blood count was suggestive of pancytopenia with hemoglobin of 10.8 g/dL, total white cell count 3.36 (1000/uL) (absolute neutrophil count 490 micro/L), platelets 19,000, serum albumin 3.1 g/dL, ESR elevated at 83 mm/hr, CRP elevated at 86.6 mg/L, and ferritin mildly elevated at 625 ng/mL. Peripheral blood smear showed signs of bone marrow suppression but no signs of hemolysis or inflammation. Serum methotrexate levels were minimally detectable at 0.05 umol/L. Methotrexate was held, within 48 hours of admission; his WBC dropped to 1.48, Hgb 9.9, and platelets 15,000. ANC reached a nadir of 220. He was treated with broad spectrum antibiotics, high-dose folic acid, fluconazole for oral thrush, and intravenous bicarbonate and leucovorin supplementation, dosed at PO 20 mg daily. On day 7, his blood count showed improvement along with improvement in his symptoms. The patient was discharged home on day 8th of hospitalization and upon one month follow-up in rheumatology clinic, his complete blood count had normalized. This case highlights multiple risk factors that triggered pancytopenia in our elderly patient, resulting in acute methotrexate toxicity.

Global signal peptide profiling reveals principles of selective Sec61 inhibition.

Cotransins target the Sec61 translocon and inhibit the biogenesis of an undefined subset of secretory and membrane proteins. Remarkably, cotransin inhibition depends on the unique signal peptide (SP) of each Sec61 client, which is required for cotranslational translocation into the endoplasmic reticulum. It remains unknown how an SP's amino acid sequence and biophysical properties confer sensitivity to structurally distinct cotransins. Here we describe a fluorescence-based, pooled-cell screening platform to interrogate nearly all human SPs in parallel. We profiled two cotransins with distinct effects on cancer cells and discovered a small subset of SPs, including the oncoprotein human epidermal growth factor receptor 3 (HER3), with increased sensitivity to the more selective cotransin, KZR-9873. By comparing divergent mouse and human orthologs, we unveiled a position-dependent effect of arginine on SP sensitivity. Our multiplexed profiling platform reveals how cotransins can exploit subtle sequence differences to achieve SP discrimination.

Gluteal Tendinopathy Is Associated With Lower Patient-Reported Outcome Measures in Total Hip Arthroplasty With a Posterior Approach: A Prospective Cohort Study of 1,538 Patients.

BACKGROUND: Gluteal tendinopathy (GT) is found in 20 to 25% of patients undergoing total hip arthroplasty (THA). Despite this, there is a scarcity of literature assessing the association between GT and THA outcomes. The aim of this study was to evaluate whether intraoperative diagnosis of GT negatively affected postoperative outcomes. METHODS: Consecutive patients undergoing primary THA for osteoarthritis via a posterior approach over 5 years were recruited in a prospective study. Gluteal tendinopathy was assessed and graded at the time of surgery, but not repaired. A total of 1,538 (93%) completed the patient-reported outcome measures (PROMs) at 1 year after surgery and were included in the analysis. The PROMs included the Oxford Hip Score (OHS), Hip Disability and Osteoarthritis Outcome Score Joint Replacement (HOOS JR), and EuroQol 5-Dimension, and were collected preoperatively and one year after THA. RESULTS: The gluteal tendons were graded as 4 distinct grades: normal (n = 1,023, 66%), tendinopathy but no tear (n = 337, 22%), partial thickness tear (n = 131, 9%), and full thickness tear (n = 47, 3%). The occurrence of GT was associated with age, body mass index, and sex. There was no significant difference in baseline OHS or HOOS JR scores according to GT grade. As GT grade increased, lower median 1-year OHS (P = .001) and HOOS JR (P = .016) were observed. This association was confirmed by linear regression analysis with 1-year OHS (B = 0.5, 95% CI = -0.9 to -0.1, P = .011) when controlled for age and sex. CONCLUSIONS: Gluteal tendinopathy was commonly observed and was associated with inferior 1-year PROMs in patients undergoing THA via posterior approach. Increasing degree of tendinopathy was a negative prognostic factor for outcomes and patient satisfaction. LEVEL OF EVIDENCE: Level 2 (High quality prospective cohort study).

A Longitudinal Analysis of Trajectories and Predictors of Fidelity Using the SafeCare Parenting Model.

Evidence-based practice (EBP) fidelity, understood as the extent to which a program is implemented as the developers intended, is a key implementation variable which likely relates to consumer outcomes. However, studies that track fidelity longitudinally and at large scale are uncommon, and finding reliable predictors of fidelity has proven to be a complex challenge. Further, attitudes toward EBP are a potentially important predictor of fidelity, but results across the literature have been mixed. The purpose of the present study is to use data from the ongoing implementation and dissemination of the SafeCare model to better understand (1) the characteristics of SafeCare implementation fidelity trajectories, and (2) whether individual level factors predict differences in fidelity and fidelity trajectories, especially provider attitudes toward EBP. The analyses reported here include 14,778 observed fidelity sessions by 868 providers in 172 agencies. We use multilevel modeling to examine fidelity, fidelity trajectories over time, and several potential individual-level predictors of fidelity, including demographics, work history, and attitudes toward EBP. We found: (1) that SafeCare fidelity begins high at baseline (93.85% on average); (2) that SafeCare fidelity displays a statistically significant trend of positive linear growth, even among those with less positive attitudes; and (3) that positive attitudes are associated with slightly higher fidelity on average and at baseline, while negative attitudes are associated with slightly lower fidelity on average and at baseline. To our knowledge, this is the largest longitudinal analysis of EBP fidelity in a child welfare program to date, and our findings support the notion that intensive coaching supports which are titrated over time can be sufficient to ensure sustained high fidelity, at least in some cases. Further, these findings indicate that robust training and coaching processes can ensure high fidelity and fidelity growth even among providers with less positive attitudes toward EBP.

Impact of concurrent glomerulonephritis on outcomes of diffuse alveolar haemorrhage in antineutrophil cytoplasmic antibody-associated vasculitis.

OBJECTIVES: Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) commonly presents with diffuse alveolar haemorrhage (DAH) and/or glomerulonephritis. Patients who present with DAH but without kidney involvement have been understudied. METHODS: Patients with DAH diagnosed by bronchoscopy and attributed to AAV over 8.5 years were retrospectively identified through electronic medical records and bronchoscopy reporting software. Patients with end-stage kidney disease (ESKD) or prior kidney transplant were excluded. Characteristics, treatments, and outcomes were abstracted. RESULTS: 30 patients were identified with DAH secondary to AAV. Five with ESKD or prior kidney transplant, and one with concomitant anti-glomerular basement membrane disease, were excluded, leaving 24 patients for analysis. At the time of qualifying bronchoscopy, six patients had no apparent kidney involvement by AAV, while eight of 18 with kidney involvement required dialysis. Of the eight patients dialysed during the initial hospitalisation, four were declared to have ESKD and three died in the subsequent year (one of whom did both). None of the 16 patients without initial dialysis requirement developed kidney involvement requiring dialysis in the subsequent year, though three of the six without initial evidence of kidney involvement by AAV ultimately developed it. No patient without initial kidney involvement died during follow-up. CONCLUSIONS: In our cohort, patients with DAH due to AAV without initial kidney involvement did not develop kidney involvement requiring dialysis or die during the follow-up period, though half of patients without initial evidence of kidney involvement subsequently developed it. Larger studies are warranted to better characterise this population and guide medical management.

Endothelial Dysfunction in Systemic Sclerosis.

Systemic sclerosis, commonly known as scleroderma, is an autoimmune disorder characterized by vascular abnormalities, autoimmunity, and multiorgan fibrosis. The exact etiology is not known but believed to be triggered by environmental agents in a genetically susceptible host. Vascular symptoms such as the Raynaud phenomenon often precede other fibrotic manifestations such as skin thickening indicating that vascular dysfunction is the primary event. Endothelial damage and activation occur early, possibly triggered by various infectious agents and autoantibodies. Endothelial dysfunction, along with defects in endothelial progenitor cells, leads to defective angiogenesis and vasculogenesis. Endothelial to mesenchymal cell transformation is another seminal event during pathogenesis that progresses to tissue fibrosis. The goal of the review is to discuss the molecular aspect of the endothelial dysfunction that leads to the development of systemic sclerosis.

The economic impact of COVID-19 on the creative industries: a sub-regional input-output approach.

The creative industries are a strategically important sector for the Cardiff Capital Region (CCR) which houses large public sector broadcasters and an ecosystem of IT and software businesses. The CCR is an administrative boundary in Wales which captures just under half of the Welsh population but over half of the Welsh economy. The pandemic and resultant lockdown restrictions have had profound impacts on the creative industries, a sector which depends heavily on in-person interaction. The creative industries are not one homogenous sector, but a collection of different activities some of which faced different supply and demand conditions due to the COVID-19 shock. To understand the impact of the shock in fine inter-industry detail and at a sub-regional scale an input-output table for the Cardiff Capital Region (the CCRC-IO) is utilized. The CCRC-IO estimates that the direct, indirect, and induced impacts of the shock see output fall by £457 m (0.53% of CCR output), GVA by £147 m (0.58% of CCR GVA) and FTE employment by 2416 (0.58% of CCR FTE). The paper finds that the economic impact of the COVID-19 shock varies considerably by both geography and sub-sector.

Goals, challenges and strategies for wound and bleeding management in total knee arthroplasty: A modified Delphi method.

BACKGROUND: Surgical techniques related to soft tissue management play critical roles in optimizing surgical outcomes and patient satisfaction in total knee arthroplasty (TKA). Despite the importance of wound closure and bleeding management approaches, no published guidelines/consensus are available. METHODS: Twelve orthopedic surgeons participated in a modified Delphi panel consisting of 2 parts (each part comprising two rounds) from September-October 2018. Questionnaires were developed based on published evidence and guidelines on surgical techniques/materials. Questionnaires were administered via email (Round 1) or at a face-to-face meeting (subsequent rounds). Panelists ranked their agreement with each statement on a five-point Likert scale. Consensus was achieved if ≥70% of panelists selected 4/5, or 1/2. Statements not reaching consensus in Round 1 were discussed and repeated or modified in Round 2. Statements not reaching consensus in Round 2 were excluded from the final consensus framework. RESULTS: Consensus was reached on 13 goals of wound management. Panelists agreed on 38 challenges and 71 strategies addressing surgical techniques or wound closure materials for each tissue layer, and management strategies for blood loss reduction or deep vein thrombosis prophylaxis in TKA. Statements on closure of capsular and skin layers, wound irrigation, dressings and drains required repeat voting or modification to reach consensus. CONCLUSION: Consensus from Asia-Pacific TKA experts highlights the importance of wound management in optimizing TKA outcomes. The consensus framework provides a basis for future research, guidance to reduce variability in patient outcomes, and can help inform recommendations for wound management in TKA.

A Comparative Analysis of Gender Discrepancy Stress, Attitudes toward Intimate Partner Violence, and Perpetration among Young Adults in the USA and Uganda.

BACKGROUND: There is a dearth of data on the modifiable factors that contribute to violence in low- and middle-income countries, including attitudes regarding intimate partner violence (IPV) and perceptions of gender identity. We examined these factors using a cross-cultural comparison between young adults in Uganda and the United States. METHODS: A cross-sectional survey was distributed to young adults aged 18 to 25 in Uganda (n = 300) and the U.S. (n = 300). Survey questions assessed demographics, attitudes toward IPV, IPV victimization and perpetration, gender discrepancy, discrepancy stress, and alcohol use. We conducted chi-square tests, as well as bivariable and multivariable logistic regression analyses, separately for participants in each country. RESULTS: The prevalence of IPV perpetration differed significantly by country for men (58.06% in the U.S. vs. 42.73% in Uganda; p = 0.03) and women (40.00% in the U.S. vs. 14.00% in Uganda; p < 0.01). IPV victimization differed by country for men (67.74% in the U.S. vs. 51.82% in Uganda; p = 0.02) but not for women. Gender discrepancy and discrepancy stress also varied by country and by sex and were higher in the U.S. for both men and women. IPV victimization was a common risk factor for adults in both Uganda (Adj. OR = 23.47; 95% CI: 7.79, 70.22) and the U.S. (Adj. OR = 27.40; 95% CI: 9.97, 75.32). In Uganda, male sex was significantly associated with IPV perpetration in multivariable analyses (Adj. OR = 6.23; 95% CI: 2.45, 15.86), and so were IPV attitudes (Adj. OR = 2.22; 1.20, 4.10). In the U.S., a likely alcohol use disorder (AUD) was also significantly associated with IPV perpetration (Adj. OR = 7.11; 95% CI: 2.25, 22.54). CONCLUSIONS: Permissive IPV attitudes were associated with IPV perpetration among Ugandan participants, while likely AUD was associated with perpetration in U.S. PARTICIPANTS: Overall, IPV perpetration was significantly higher for U.S. males compared with Ugandan males. These findings indicate that cultural adaptations to global IPV interventions may be necessary to respond to differing needs in different countries.

Opioid use and patient outcomes in an Australian hip and knee arthroplasty cohort.

BACKGROUND: To determine the prevalence of opioid use in Australian hip (THA) or knee (TKA) cohort, and its association with outcomes. METHODS: About 837 primary THA or TKA subjects prospectively completed Oxford Scores, and Knee or Hip Osteoarthritis Outcomes Score(KOOS/HOOS) and opioid use in the previous week before arthroplasty. Subjects repeated the baseline survey at 6 months, with additional questions regarding satisfaction. RESULTS: Opioid use was reported by 19% preoperatively and 7% at 6 months. Opioid use was 46% at 6 weeks and 10% at 6 months after TKR, and 16% at 6 weeks and 4% at 6 months after THR. Preoperative opioid use was associated with back pain(OR 2.2, P = 0.006), anxiety or depression(OR 1.8, P = 0.001) and Oxford knee scores <30(OR 5.6, P = 0.021) in TKA subjects, and females in THA subjects(OR 1.7, P = 0.04). There was no difference between preoperative opioid users and non-users for satisfaction, or KOOS or HOOS scores at 6 months. 77% of patients taking opioids before surgery had ceased by 6 months, and 3% of preoperative non users reported opioid use at 6 months. Opioid use at 6 months was associated with preoperative use (OR 6.6-14.7, P < 0.001), and lower 6 month oxford scores (OR 4.4-83.6, P < 0.01). CONCLUSION: One in five used opioids before arthroplasty. Pre-operative opioid use was the strongest risk factor for opioid use at 6 months, increasing odds 7-15 times. Prolonged opioid use was rarely observed in the opioid naïve (<5% TKA and 1% THA). Preoperative opioid use was not associated with inferior outcomes or satisfaction.

Foot Pain is Common, But Frequently Improves 1 Year After Total Knee Arthroplasty.

BACKGROUND: Osteoarthritis frequently affects multiple joints through the lower limbs. This study sought to examine the incidence of foot pain in subjects undergoing total knee arthroplasty (TKA) and determine if foot symptoms improved following surgery. METHODS: Six hundred ten subjects undergoing TKA completed patient-reported outcome measures preoperatively, and at 6 and/or 12 months after surgery including the incidence and severity of foot or ankle pain, Knee Injury and Osteoarthritis Outcome Scores (KOOS) Joint Replacement, Oxford Knee Scores (OKS), EQ5D, and satisfaction. RESULTS: Foot or ankle pain was reported in 45% before, 32% at 6 months, and 36% at 12 months after TKA. Of those with preoperative foot pain, 42% at 6 months and 50% at 12 months reported no foot pain after TKA, and the Visual Analog Scale severity reduced from a mean of 4.0 before to 1.7 after surgery. Those with preoperative foot pain had lower baseline KOOS (P = .001), OKS (P = .001), and more depression/anxiety (P = .010), but experienced equivalent postoperative KOOS, OKS, and satisfaction with surgery, compared to those without foot pain. CONCLUSION: Foot or ankle pain was reported by nearly half of TKA subjects, but resolved after surgery in 50%. Those with preoperative foot pain experienced at least equivalent improvement in knee-related symptoms and mobility compared to those without foot pain. The presence of foot pain should not be a deterrent to TKA.

Place Is Power: Investing in Communities as a Systemic Leverage Point to Reduce Breast Cancer Disparities by Race.

Racial disparities in breast cancer present a vexing and complex challenge for public health. A diverse array of factors contributes to disparities in breast cancer incidence and outcomes, and, thus far, efforts to improve racial equity have yielded mixed results. Systems theory offers a model that is well-suited to addressing complex issues. In particular, the concept of a systemic leverage point offers a clue that may assist researchers, policymakers, and interventionists in formulating innovative and comprehensive approaches to eliminating racial disparities in breast cancer. Naming systemic racism as a fundamental cause of disparities, we use systems theory to identify residential segregation as a key leverage point and a driver of racial inequities across the social, economic, and environmental determinants of health. We call on researchers, policymakers, and interventionists to use a systems-informed, community-based participatory approach, aimed at harnessing the power of place, to engage directly with community stakeholders in coordinating efforts to prevent breast cancer, and work toward eliminating disparities in communities of color.

Adaptation and implementation of a parenting curriculum in a refugee/immigrant community using a task-shifting approach: a study protocol.

BACKGROUND: Delivering evidence-based interventions to refugee and immigrant families is difficult for several reasons, including language and cultural issues, and access and trust issues that can lead to an unwillingness to engage with the typical intervention delivery systems. Adapting both the intervention and the delivery system for evidence-based interventions can make those interventions more appropriate and palatable for the targeted population, increasing uptake and effectiveness. This study focuses on the adaptation of the SafeCare© parenting model, and its delivery through either standard implementation methods via community-based organizations (CBO) and a task-shifted implementation in which members of the Afghans, Burmese, Congolese community will be trained to deliver SafeCare. METHOD: An adaptation team consisting of community members, members of CBO, and SafeCare experts will engage a structured process to adapt the SafeCare curriculum for each targeted community. Adaptations will focus on both the model and the delivery of it. Data collection of the adaptation process will focus on documenting adaptations and team member's engagement and satisfaction with the process. SafeCare will be implemented in each community in two ways: standard implementation and task-shifted implementation. Standard implementation will be delivered by CBOs (n = 120), and task-shifted implementation will be delivered by community members (n = 120). All interventionists will be trained in a standard format, and will receive post-training support. Both implementation metrics and family outcomes will be assessed. Implementation metrics will include ongoing adaptations, delivery of services, fidelity, skill uptake by families, engagement/completion, and satisfaction with services. Family outcomes will include assessments at three time points (pre, post, and 6 months) of positive parenting, parent-child relationship, parenting stress, and child behavioral health. DISCUSSION: The need for adapting of evidence-based programs and delivery methods for specific populations continues to be an important research question in implementation science. The goal of this study is to better understand an adaptation process and delivery method for three unique populations. We hope the study will inform other efforts to deliver health intervention to refugee communities and ultimately improve refugee health.

Conforming patellar button design improves outcome of total knee arthroplasty.

BACKGROUND: Patellar resurfacing is commonly performed during total knee arthroplasty (TKA), and the patellar button design can vary within a TKA implant. Implant design is known to affect patella kinematics, contact mechanics, and ultimately the outcome of TKA. The aim of this study was to compare the patient-reported outcomes of TKA with either a conforming (CP) or medialized dome (MD) patellar component. METHODS: The study was a prospective cohort study of 100 TKAs performed between December 2015 and August 2017. We compared a consecutive series of 50 TKA subjects with a CP, with the previous 50 TKA subjects with an MD patella. The primary outcome measure was difference in Knee Injury and Osteoarthritis Score (KOOS) at 12 months. Other patient-reported outcome measures included EQ5D as a general health measure, and patient satisfaction. RESULTS: There was no significant difference in baseline characteristics, KOOS, or EQ5D between the two groups. At 12 months, the CP Group had a higher mean KOOS function score (87 vs. 80, P = 0.04), and greater patient satisfaction (98% vs. 82% satisfied, P = 0.009) compared with the MD group. The CP Group had significantly lower frequency of pain with level walking, less difficulty with stairs, and lower mean EQ5D mobility at 12 months compared with the MD group. CONCLUSIONS: TKA performed using a conforming patella has superior results over a medialized dome patellar component for KOOS function, patient satisfaction, walking pain, stair performance, and mobility at 12 months postoperatively. The differences observed with the change in patellar design may be unique to this prosthesis.

Improvement in Sleep Patterns After Hip and Knee Arthroplasty: A Prospective Study in 780 Patients.

BACKGROUND: This study assessed change in sleep patterns before and after total hip arthroplasty (THA) and total knee arthroplasty (TKA) and its relationship to patient-reported outcome measures (PROMs). METHODS: Between July 2016 and June 2018, surgical data and PROMs were collected on 780 subjects before and 12 months after THA or TKA. PROMs included Knee Injury and Osteoarthritis Outcome Score, Hip Disability and Osteoarthritis Outcome Score, patient satisfaction, and 2 questions from the Pittsburgh Sleep Quality Index. RESULTS: Before surgery, 35% (270 of 780) reported poor quality sleep. Sleep quality and duration were worse in females over males, and in THA patients (39%) over TKA patients (30%; P = .011). Of those reporting bad sleep, 74% (201 of 270) were improved after arthroplasty. Satisfaction was higher in subjects reporting good sleep quality (626 of 676; 93%) compared with those reporting bad sleep quality (67 of 86; 78%) (P = .001). Sleep was positively correlated with better Hip Disability and Osteoarthritis Outcome Score/Knee Injury and Osteoarthritis Outcome Score (r = 0.2-0.3). CONCLUSION: Improvement in sleep quality and duration can be expected after THA and TKA and is associated with better outcome scores and satisfaction.

Effect of the SafeCare© intervention on parenting outcomes among parents in child welfare systems: A cluster randomized trial.

Child maltreatment has long-lasting negative impacts, and interventions are needed to improve caregiver's parenting skills to prevent maltreatment. This paper reports on a randomized trial comparing the SafeCare© model to services as usual (SAU) for child-welfare referred caregivers. SafeCare is an 18-session behavioral parenting program that teaches skills in positive parent-child interactions, home safety, and child health. SAU is generally unstructured and includes support, crisis management, referrals for need, and parenting education. Teams of providers at nine sites were randomized to implement SafeCare (19 teams; 119 providers) or continue SAU (17 teams; 118 providers). Two-hundred eighty eight caregivers (193 SafeCare; 95 SAU) with children aged 0-5 who were receiving services agreed to complete a baseline and 6-month assessment. Assessments measured positive parenting behaviors, parenting stress, protective factors, and neglectful behaviors using validated scales. Participants were primarily white (74.6%), female (87.0%), and low-income (68.6%), and had a mean age of 29. Latent change score models (LCSM) using a sandwich estimator consistent with the trial design were used to examine changes in 13 outcomes. Results indicated that SafeCare had small to medium effects for improving several parenting outcomes including supporting positive child behaviors (d = 0.46), proactive parenting (d = 0.25), and two aspects of parenting stress (d = 0.28 and .30). No differential change between groups was found for other indicators, including all indicators of neglect. Parenting programs such as SafeCare offer a promising mode of intervention for child welfare systems. Scale-up of parenting programs can improve parenting, improve child outcomes, and potentially reduce maltreatment. CLINICALTRIAL.GOV REGISTRATION NUMBER: NCT02549287.

Utility of preoperative blood screening before hip and knee arthroplasty.

BACKGROUND: It is engrained in medical training that routine blood screening prior to arthroplasty is necessary for optimal patient care. There is little evidence to support their utility and the aggregate cost to the health system. The purpose of this study was to evaluate preoperative blood screening by identifying the frequency of an abnormal result and to examine the influence of age, gender and body mass index on the frequency of abnormal blood pathology. METHODS: This is a retrospective review of 1000 patients from a single centre who underwent elective primary hip or knee arthroplasty from 2015 to 2017. Abnormal blood results were identified and clinically relevant intervals were created for routine markers. RESULTS: A total of 939 patients had available pathology results with 84% identified as having an abnormal result and 47% having a clinically important range. Abnormal liver function tests and ferritin were most common. With increasing age, there was a significant increase in rates of abnormal clinically important range, renal dysfunction, abnormal haemoglobin and erythrocyte sedimentation rate. Males and patients with body mass index >40 had an increased rate of abnormal results, particularly liver function tests. CONCLUSION: The ordering of preoperative investigations prior to lower limb arthroplasty is recommended by the National Institute for Health and Care Excellence guidelines, alleviating concern of post-operative complications and covering medicolegal issues. Our study determined a high frequency of abnormal results, justifying routine blood screening is recommended prior to surgery, particularly for the elderly, males and obese patients.

Does adoption of an evidence-based practice lead to job turnover? Results from a randomized trial.

It is important to understand the impact of implementation of evidence-based practices (EBPs) on the workforce. EBP implementation can increase job demands, stress, and burnout, and may thereby exacerbate turnover. This study examined the effects of implementation of an EBP on turnover among staff at nine child welfare agencies. A total of 102 providers were randomized to either adopt an EBP, SafeCare© , or continue providing services as usual. Participants completed a baseline survey assessing demographics, attitudes toward EBPs, and organizational functioning, and provider turnover was recorded for up to 18 months following implementation. The overall turnover rate was 35%, but did not differ by EBP assignment (odds ratio [OR] = 1.27; 95% confidence interval [0.66, 2.45]). Variables associated with turnover included age (OR = 0.92), years since degree completion (OR = 0.94), prior exposure to EBP (OR = 3.91), believing that adopting an EBP was burdensome (OR = 0.52), and motivation for change (OR = 0.89). EBP assignment moderated two aspects of negative attitudes toward EBP (divergence and monitoring) to predict turnover; those attitudes were only positively related to turnover for individuals assigned to the EBP (OR = 1.46, 1.16). Implications of the findings for implementation are discussed.

Inpatient rehabilitation did not positively affect 6-month patient-reported outcomes after hip or knee arthroplasty.

BACKGROUND: The aim of this study was to compare patient-reported outcomes 6 months after hip or knee arthroplasty in subjects who were discharged to home compared to those who attended inpatient rehabilitation. METHODS: Seven hundred and forty-eight consecutive total hip or knee replacement patients were identified from a prospective database. Preoperative and 6-month post-operative patient-reported outcome measures were recorded. Forty-four patients discharged directly to home were cohort matched by age, gender, procedure and surgeon to 44 patients from the cohort who received inpatient care. Patient outcomes were compared using SPSS version 24 software. RESULTS: Both cohorts saw significant improvements from baseline at 6 months. Median length of rehabilitation for the inpatient group was 7 days (4-16 days). There was no significant difference between the groups based on patient-reported outcomes. There was a clinically significant difference (P = 0.047) in the body mass index of the Home Group (mean = 27) to Rehab Group (mean = 29). CONCLUSION: Our study has shown that inpatient rehabilitation after hip or knee arthroplasty did not positively affect 6-month patient-reported satisfaction, expectation, pain, quality of life, activities of daily living scores, when compared with subjects who were discharged direct to home. A significant average saving of $5600 per patient with the use of home discharge is a promising avenue for health cost reduction, and health resource distribution.