Despite the overall effectiveness of total knee arthroplasty (TKA), a subset of patients do not experience expected improvements in pain, physical function, and quality of life as documented by patient-reported outcome measures (PROMs), which assess a patient’s physical and emotional health and pain. It is therefore important to develop preoperative tools capable of identifying patients unlikely to improve by a clinically important margin after surgery.
Questions/purposesThe purpose of this study was to determine if an association exists between preoperative PROM scores and patients’ likelihood of experiencing a clinically meaningful change in function 1 year after TKA.
MethodsA retrospective study design was used to evaluate preoperative and 1-year postoperative Knee injury and Osteoarthritis Outcome Score (KOOS) and SF-12 version 2 (SF12v2) scores from 562 patients who underwent primary unilateral TKA. This cohort represented 75% of the 750 patients who underwent surgery during that time period; a total of 188 others (25%) either did not complete PROM scores at the designated times or were lost to follow-up. Minimum clinically important differences (MCIDs) were calculated for each PROM using a distribution-based method and were used to define meaningful clinical improvement. MCID values for KOOS and SF12v2 physical component summary (PCS) scores were calculated to be 10 and 5, respectively. A receiver operating characteristic analysis was used to determine threshold values for preoperative KOOS and SF12v2 PCS scores and their respective predictive abilities. Threshold values defined the point after which the likelihood of clinically meaningful improvement began to diminish. Multivariate regression was used to control for the effect of preoperative mental and emotional health, patient attributes quantified by SF12v2 mental component summary (MCS) scores, on patients’ likelihood of experiencing meaningful improvement in function after surgery.
ResultsThreshold values for preoperative KOOS and SF12v2 PCS scores were a maximum of 58 (area under the curve [AUC], 0.76; p < 0.001) and 34 (AUC, 0.65; p < 0.001), respectively. Patients scoring above these thresholds, indicating better preoperative function, were less likely to experience a clinically meaningful improvement in function after TKA. When accounting for mental and emotional health with a multivariate analysis, the predictive ability of both KOOS and SF12v2 PCS threshold values improved (AUCs increased to 0.80 and 0.71, respectively). Better preoperative mental and emotional health, as reflected by a higher MCS score, resulted in higher threshold values for KOOS and SF12v2 PCS.
ConclusionsWe identified preoperative PROM threshold values that are associated with clinically meaningful improvements in functional outcome after TKA. Patients with preoperative KOOS or SF12v2 PCS scores above the defined threshold values have a diminishing probability of experiencing clinically meaningful improvement after TKA. Patients with worse baseline mental and emotional health (as defined by SF12v2 MCS score) have a lower probability of experiencing clinically important levels of functional improvement after surgery. The results of this study are directly applicable to patient-centered informed decision-making tools and may be used to facilitate discussions with patients regarding the expected benefit after TKA.
Level of EvidenceLevel III, prognostic study.
相似文献Background
Cyclosporine (CsA) is widely used after heart transplantation. The purpose of this prospective randomized study was to evaluate the safety and efficacy of reduction of CsA blood level to one-half of the traditional blood concentration under a regimen of everolimus (EVL), CsA, and steroid.Materials and Methods
This prospective, 6 month, randomized, open-label study included adult (aged 18 to 65 years) recipients of a primary heart transplant with serum creatinine ≤2.8 mg/dL. Among 52 patients who underwent heart transplantation from December 2004 to March 2006 we excluded those who were hepatitis B or C carriers, who were recipients of organs from donors >60 years old, had cold ischemia time >6 hours, or had plasma renin activity ≥25%. All patients received CsA (C2 blood level 1000-1400 ng/mL), EVL (C0 target 3-8 ng/mL), and corticosteroids to day 60, before random entry into one of 2 groups: SE (C2 blood level from days 60-149 = 800-1200 ng/mL, and days 150-180 C2 = 600-1000 ng/mL), or RE group with CsA reduced by one-half after 3 months (days 90-149 C2 = 400-600 ng/mL, and from days 150-180 C2 = 300-500 ng/mL).Results
The 25 recipients eligible for this study included 13 patients in the SE and 12 in the RE group. There was no operative mortality in either group. No death or graft loss was noted within 6-months in either group. Mean serum creatinine at month 6 tended to be lower in the RE cohort (1.23 ± 0.44 mg/dL versus 1.55 ± 0.85 mg/dL; P = .093). Biopsy-proven acute rejection ≥ grade 3A was observed in only 1 patient (7.7%), who was in the SE group. There were no acute rejection episodes associated with hemodynamic compromise. The incidences of adverse events in each group were similar.Conclusions
Concentration-controlled EVL (C0 target 3-8 ng/mL) in combination with reduced CsA exposure of one-half the usual concentration achieved good efficacy and safety over 6 months. The renal function at 6 months among the RE group showed a trend toward improvement, suggesting a benefit of halving the target CsA blood level after heart transplantation. 相似文献Background
This study investigated the effects of dronabinol on pain, nausea, and length of stay following total joint arthroplasty (TJA).Methods
We retrospectively compared 81 consecutive primary TJA patients who received 5 mg of dronabinol twice daily in addition to a standard multimodal pain regimen with a matched cohort of 162 TJA patients who received only the standard regimen. A single surgeon performed all surgeries. Patient demographics, length of stay, opioid morphine equivalents (MEs) consumed, reports of nausea/vomiting, discharge destination, distance walked in physical therapy, and visual analog scale pain scores were collected for both groups. Student’s t-tests as well as chi-square or Mann-Whitney U-tests were used for statistical comparisons.Results
There were no significant differences between the 2 groups for age, gender, body mass index, American Society of Anesthesiologists score, anesthesia type, visual analog scale scores, distance walked with physical therapy, discharge disposition, or episodes of nausea/vomiting. The mean length of stay in the dronabinol group was significantly shorter at 2.3 ± 0.9 days versus 3.0 ± 1.2 days in the control group (P = .02). In the context of a shorter stay, the dronabinol group consumed significantly fewer total MEs (252.5 ± 131.5 vs 313.3 ± 185.4 mg, P = .0088). Although the dronabinol group consumed fewer MEs per day and per length of stay on average, neither of these achieved statistical significance. No side effects of dronabinol were reported.Conclusion
These findings suggest that further investigation into the role of cannabinoid medications for non-opioid pain control in the post-arthroplasty patient may hold merit. 相似文献The Knee Society Score (KSS) instrument is one of the most commonly reported primary outcome measures for total knee arthroplasty (TKA). Originally developed in 1989, the KSS was expanded and updated in 2011; however, the original KSS does not directly translate into the 2011 KSS. To date, no conversion algorithm has been developed, hindering the ability of researchers to adopt the 2011 KSS while maintaining their historical/longitudinal original KSS data.
Questions/purposesThe purpose of this study is to develop regression equations to map the original KSS to the 2011 KSS, allowing original and 2011 KSS data sets to be combined.
MethodsIn this multicenter, nonrandomized study, a convenience sample of 815 patients undergoing primary TKA completed the original KSS questionnaire and the 2011 KSS questionnaire. Additionally, patient gender, patient age, and patient ethnicity were recorded. These data were then used to generate regression models to estimate the 2011 objective and function KSS from the original KSS. Of the 815 study patients, 476 (58%) were female and 339 (42%) were male at an average age of 67 years (SD 9.4). Roughly half of patients were assessed preoperatively (430 of 815 [53%]) with the remaining patients assessed postoperatively (386 of 815 [47%]). The average followup for postoperative patients was 4.4 years (SD 3.5 years).
ResultsWe have created a spreadsheet that can be used by individuals with no statistical training to crosswalk the objective and function subscores from the original KSS to the 2011 KSS [Supplemental materials are available with the online version of CORR®.]. The predictive model very accurately estimated the 2011 objective score, on average, within 0.22 points on the 100-point 2011 objective KSS at the cohort or aggregate level. The objective model accurately estimated the 2011 objective KSS within 8.83 points, on average, of the actual 2011 objective KSS at the individual patient level. However, as a result of large outliers, 37% of the estimated 2011 objective KSS were greater than 10 points from the actual 2011 objective KSS. To illustrate, if you use the model to estimate the 2011 objective KSS on a cohort of 100 patients, a patient with an original objective KSS of 88 will have an estimated objective KSS between 79 and 97 points. On the other hand, if you calculate an average original objective KSS of 88 for all 100 patients, the estimated average 2011 objective KSS will be 88 for the group. The predictive model accurately estimated the 2011 function KSS within 0.14 points on the 1000-point 2011 function KSS at the cohort level. At the patient level, the 2011 function KSS was also estimated within 8.8 points of the actual 2011 function KSS. However, 43% of the estimated function scores were greater than 10 points of the actual 2011 function KSS.
ConclusionsClinicians and researchers can input their original KSS with demographic data into these equations to estimate the 2011 KSS objective and function scores. The small prediction error of 0.22 points that we calculated indicates that these models can be used to estimate the 2011 objective and function KSS at the aggregated cohort level. Although the average error score was within 10 points at the individual patient level, there was a high percentage of large errors resulting from outliers in the data set. These outliers seemed to be related to patients with excellent range of motion who had substantial pain and limited function or patients who have poor range of motion with excellent function and little pain. This may be inherent with the KSS or with the study sample. Nevertheless, one must use caution when estimating at the patient level. Additionally, the accuracy of the prediction scores decreases if any of the demographic variables included in this study are not available.
相似文献Background
The aim of this controlled multicenter study is to evaluate the clinical and radiologic outcomes of primary total knee arthroplasty (TKA) using single-use fully disposable and patient-specific cutting guides (SU) and compare the results to those obtained with traditional patient-specific cutting guides (PSI) vs conventional instrumentation (CI).Methods
Seventy consecutive patients had their TKA performed using SU. They were compared to 140 historical patients requiring TKA that were randomized to have the procedure performed using PSI vs CI. The primary measure outcome was mechanical axis as measured on a standing long-leg radiograph using the hip-knee-ankle angle. Secondary outcome measures were Knee Society and Oxford knee scores, operative time, need for postoperative transfusion, and length of hospital stay.Results
The mean hip-knee-ankle value was 179.8° (standard deviation [SD] 3.1°), 179.2° (SD 2.9°), and 178.3° (SD 2.5°) in the CI, PSI and SU groups, respectively (P = .0082). Outliers were identified in 16 of 65 (24.6%), 15 of 67 (22.4%), and 14 of 70 (20.0%) knees in the CI, PSI, and SU group, respectively (P = .81). There was no significant difference in the clinical results (P = .29 and .19, respectively). Operative time, number of unit transfusion, and length of hospital stay were not significantly different between the 3 groups (P = .45, .31, and 0.98, respectively).Conclusion
The use of an SU in TKA provided similar clinical and radiologic results to those obtained with traditional PSI and CI. The potential economic advantages of single-use instrumentation in primary TKA require further investigation. 相似文献Purpose of review
With the recognition that neurodegeneration represents the principal substrate of disability in multiple sclerosis (MS), there has been increased strives towards identifying biomarkers for accurately quantifying and tracking neurodegeneration during the disease course. The retina provides an opportune “window” into the central nervous system (CNS) in MS, with retinal changes in MS reflecting not only local, but also global aspects of neurodegeneration and inflammation operative in the disease. Optical coherence tomography (OCT) is a rapid, inexpensive, reproducible, high-resolution imaging technique allowing accurate quantification of discrete retinal layers. OCT determined thinning of inner retinal layers such as the retinal nerve fiber layer (RNFL) and in particular the composite of the ganglion cell and inner plexiform (GCIP) layers, predominantly related to optic neuropathy, have been shown to not only correlate with high and low contrast visual function in MS, but also global MS disability scores, as well as whole brain and particularly gray matter volumes. Rates of GCIP thinning have been shown to be accelerated among MS patients exhibiting inflammatory activity outside of the visual pathways, as well as disability progression during follow-up. Moreover, baseline RNFL thickness in MS has been shown to have utility for predicting future disability accumulation. On the other hand, thickening of the inner nuclear layer (INL) in MS, the pathophysiologic basis of which remains to be elucidated, has been found to predict the development of clinical and radiological inflammatory activity, as well as subsequent disability progression in MS. Given the potential for OCT to provide insight into neurodegeneration and inflammation occurring in MS, this review focuses on the potential utility of OCT within the clinical setting to influence treatment decisions for MS patients.Recent findings
The evolution of spectral domain-OCT technology, with improved resolution and reproducibility allowing intra-retinal layer segmentation, has facilitated the determination that the OCT derived measure GCIP thickness is a highly accurate measure for quantifying and tracking neurodegeneration, and conversely neuroprotection, in MS. The strong relationships between rates of GCIP and brain atrophy across MS subtypes over time underpin the insight derived regarding the global MS disease process from OCT and highlight OCT as an excellent complementary tool to magnetic resonance imaging (MRI) for tracking MS patients. More recently, longitudinal studies are emerging which support the utility of OCT for monitoring the differential effects of disease-modifying therapies (DMTs) in MS.Summary
Although further work is required, there is mounting evidence supporting the utility of OCT in the clinical setting to monitor disease course in individual patients with MS and to aid in the prediction of disease course. As pharmacological treatment options in MS expand to also include potentially neuroprotective and/or remyelinating or neurorestorative drugs, OCT as a biomarker of neurodegeneration and neuroprotection (and neuroinflammation to a lesser degree) may become an invaluable tool in both the research and clinical settings.Extremity sarcoma has a preponderance to present late with advanced stage at diagnosis. It is important to know why these patients die early from sarcoma and to predict those at high risk. Currently we have mid- to long-term outcome data on which to counsel patients and support treatment decisions, but in contrast to other cancer groups, very little on short-term mortality. Bayesian belief network modeling has been used to develop decision-support tools in various oncologic diagnoses, but to our knowledge, this approach has not been applied to patients with extremity sarcoma.
Questions/purposesWe sought to (1) determine whether a Bayesian belief network could be used to estimate the likelihood of 1-year mortality using receiver operator characteristic analysis; (2) describe the hierarchal relationships between prognostic and outcome variables; and (3) determine whether the model was suitable for clinical use using decision curve analysis.
MethodsWe considered all patients treated for primary bone sarcoma between 1970 and 2012, and excluded secondary metastasis, presentation with local recurrence, and benign tumors. The institution’s database yielded 3499 patients, of which six (0.2%) were excluded. Data extracted for analysis focused on patient demographics (age, sex), tumor characteristics at diagnosis (size, metastasis, pathologic fracture), survival, and cause of death. A Bayesian belief network generated conditional probabilities of variables and survival outcome at 1 year. A lift analysis determined the hierarchal relationship of variables. Internal validation of 699 test patients (20% dataset) determined model accuracy. Decision curve analysis was performed comparing net benefit (capped at 85.5%) for all threshold probabilities (survival output from model).
ResultsWe successfully generated a Bayesian belief network with five first-degree associates and describe their conditional relationship with survival after the diagnosis of primary bone sarcoma. On internal validation, the resultant model showed good predictive accuracy (area under the curve [AUC] = 0.767; 95% CI, 0.72–0.83). The factors that predict the outcome of interest, 1-year mortality, in order of relative importance are synchronous metastasis (6.4), patient’s age (3), tumor size (2.1), histologic grade (1.8), and presentation with a pathologic fracture (1). Patient’s sex, tumor location, and inadvertent excision were second-degree associates and not directly related to the outcome of interest. Decision curve analysis shows that clinicians can accurately base treatment decisions on the 1-year model rather than assuming all patients, or no patients, will survive greater than 1 year. For threshold probabilities less than approximately 0.5, the model is no better or no worse than assuming all patients will survive.
ConclusionsWe showed that a Bayesian belief network can be used to predict 1-year mortality in patients presenting with a primary malignancy of bone and quantified the primary factors responsible for an increased risk of death. Synchronous metastasis, patient’s age, and the size of the tumor had the largest prognostic effect. We believe models such as these can be useful as clinical decision-support tools and, when properly externally validated, provide clinicians and patients with information germane to the treatment of bone sarcomas.
Clinical RelevanceBone sarcomas are difficult to treat requiring multidisciplinary input to strategize management. An evidence-based survival prediction can be a powerful adjunctive to clinicians in this scenario. We believe the short-term predictions can be used to evaluate services, with 1-year mortality already being a quality indicator. Mortality predictors also can be incorporated in clinical trials, for example, to identify patients who are least likely to experience the side effects of experimental toxic chemotherapeutic agents.
相似文献