The complexity of care for patients with rheumatoid arthritis: metrics for better understanding chronic disease care

BACKGROUND: Patients with rheumatoid arthritis (RA) provide an important opportunity for understanding care of patients with a serious chronic condition. OBJECTIVES: We sought to characterize the complexity of care for patients with RA, including metrics describing the patient, the disease, and use of the health care system across time and place. METHODS: We undertook a prospective cohort study of 568 community-dwelling patients with RA by using observational data from clinically detailed telephone interviews at baseline and 2 years later in addition to medical record abstraction. Health status, comorbidity, use of disease-modifying antirheumatic drugs, visits, providers, provider types, encounter settings, and the discontinuity between patients and providers were studied. RESULTS: Within a 12-month window, 568 patients had 8686 outpatient encounters with the health care system with a mean of 3.41 unique providers per patient associated with a mean of 5 primary care and 6 rheumatologist visits. Half did not see a primary care physician, and 20% did not see a rheumatologist during 6-month periods despite their use of potentially toxic drugs, a mean of 4 comorbidities and progressive RA. Over the course of 24 months, 29% of patients changed their primary care provider, and 15% changed their rheumatologist. Patients were moderately impaired with mean SF-12 physical component score 37 (SD, 9). CONCLUSION: Patients with RA have frequent encounters with multiple providers and also frequent discontinuity of care. Recognizing the complexity of the care of patients with a chronic disease across multiple dimensions provides an opportunity to better understand challenges and opportunities in delivering high quality care.     

Total hip arthroplasty and sexual activity: a systematic review

MUSCULOSKELETAL SURGERY - Hip discomfort due to degenerative pathologies causes limitations in the everyday activities of patients, including sexual activity. To address such limitations, patients...     

Using Interpretation Bias Modification to Reduce Anger in Veterans with Posttraumatic Stress Disorder: A Pilot Study

Difficulty controlling anger is the most commonly reported reintegration concern among veterans with posttraumatic stress disorder (PTSD). One of the mechanisms associated with problematic anger is a tendency to interpret ambiguous interpersonal situations as hostile, known as the hostile interpretation bias (HIB). A computer-based interpretation bias modification (IBM) intervention has been shown to successfully reduce HIB and anger but has not been tested in veterans with PTSD. The current study was a pilot trial of this IBM intervention modified to address problematic anger among veterans with PTSD. Veterans with PTSD and a high level of anger (N = 7) completed eight sessions of IBM treatment over the course of 4 weeks. Participants completed self-report questionnaires at pre- and posttreatment assessment visits, as well as a treatment acceptability interview at posttreatment. Veterans experienced large reductions in hostile interpretation bias and anger from pre- to posttreatment, ds = 1.03–1.96, although these estimates may be unstable due to the small sample size. The feasibility for recruitment, retention, and treatment completion were high. Questionnaire and interview data demonstrated that most participants were satisfied with the treatment and found it helpful and easy to use. Overall, IBM for anger was feasible and acceptable to veterans with PTSD and was associated with reductions in hostile interpretations and self-reported anger outcomes. Further research examining this approach is warranted.     

Comparing the da Vinci Si Single Console and Dual Console in Teaching Novice Surgeons Suturing Techniques

Background and Objectives:

Robot-assisted laparoscopic surgery is often taught with the surgical mentor at the surgeon console and the trainee at the patient''s bedside. The da Vinci dual console (Intuitive Surgical, Sunnyvale, California) allows a surgical mentor to teach with both the mentor and the trainee working at a surgeon console simultaneously. The purpose of this study is to evaluate the effectiveness of the dual console versus the single console for teaching medical students robotic tasks.

Methods:

Forty novice medical students were randomized to either the da Vinci single-console or dual-console group and were taught 4 knot-tying techniques by a surgical mentor. The students were timed while performing the tasks.

Results:

No statistically significant differences in mean task times were observed between the single- and dual-console groups: interrupted stitch with a 2-handed knot (300 seconds for single vs 294 seconds for dual, P = .59), interrupted stitch with a 1-handed knot (198 seconds for single vs 212 seconds for dual, P = .88), figure-of-8 stitch with a 2-handed knot (261 seconds for single vs 219 seconds for dual, P = .20), and figure-of-8 stitch with a 1-handed knot (200 seconds for single vs 199 seconds for dual, P = .53).

Conclusion:

No significant difference was observed in performance time when teaching knot-tying techniques to medical students using the da Vinci dual console compared with the single console. More research needs to be performed on the utility of the da Vinci dual console in surgical training.     

Influenza and Other Respiratory Viruses: Impact of nonpharmaceutical interventions on laboratory detections of influenza A and B in Canada

BackgroundThe first coronavirus disease 2019 (COVID-19) case was reported in Canada on January 25, 2020. In response to the imminent outbreak, many provincial and territorial health authorities implemented nonpharmaceutical public health measures to curb the spread of disease. “Social distancing” measures included restrictions on group gatherings; cancellation of sports, cultural and religious events and gatherings; recommended physical distancing between people; school and daycare closures; reductions in non-essential services; and closures of businesses.ObjectivesTo evaluate the impact of the combined nonpharmaceutical interventions imposed in March 2020 on influenza A and B epidemiology by comparing national laboratory surveillance data from the intervention period with 9-year historical influenza season control data.MethodsWe obtained epidemiologic data on laboratory influenza A and B detections and test volumes from the Canadian national influenza surveillance system for the epidemiologic period December 29, 2019 (epidemiologic week 1) through May 2, 2020 (epidemiologic week 18). COVID-19-related social distancing measures were implemented in Canada from epidemiologic week 10 of this period. We compared influenza A and B laboratory detections and test volumes and trends in detection during the 2019–20 influenza season with those of the previous nine influenza seasons for evidence of changes in epidemiologic trends.ResultsWhile influenza detections the week prior to the implementation of social distancing measures did not differ statistically from the previous nine seasons, a steep decline in positivity occurred between epidemiologic weeks 10 and 14 (March 8–April 4, 2020). Both the percent positive on week 14 (p≤0.001) and rate of decline between weeks 10 and 14 (p=0.003) were significantly different from mean historical data.ConclusionThe data show a dramatic decrease in influenza A and B laboratory detections concurrent with social distancing measures and nonpharmaceutical interventions in Canada. The impact of these measures on influenza transmission may be generalizable to other respiratory viral illnesses during the study period, including COVID-19.     

Long-term safety and effectiveness of paroxysmal atrial fibrillation ablation using a porous tip contact force-sensing catheter from the SMART SF trial

Journal of Interventional Cardiac Electrophysiology - The prospective, multicenter SMART SF trial demonstrated the acute safety and effectiveness of the 56-hole porous tip irrigated contact force...