Are Medicare's Nursing Home Compare Ratings Accurate Predictors of 90-Day Complications,Readmission, and Bundle Cost for Patients Undergoing Primary Total Joint Arthroplasty?

Background

Nursing Home Compare (NHC) ratings, created and maintained by Medicare, are used by both hospitals and consumers to aid in the skilled nursing facility (SNF) selection process. To date, no studies have linked NHC ratings to actual episode-based outcomes. The purpose of this study was to evaluate whether NHC ratings are valid predictors of 90-day complications, readmission, and bundle costs for patients discharged to an SNF after primary total joint arthroplasty (TJA).

Effect of a patellar realignment brace on patellofemoral relationships: Evaluation with kinematic MR imaging

The effect of a newly developed patellar realignment brace was evaluated in 21 patellofemoral joints (19 patients) with patellar subluxation (13 joints with lateral subluxation and eight with medial subluxation) by using active-movement, loaded kinematic magnetic resonance (MR) imaging. Sixteen patellofemoral joints (76%) demonstrated a qualitative correction of or improvement in patellar subluxation (ie, centralization of the patella or a decrease in the displacement of the patella) after application of the brace. Four of the five “failures” occurred in patellofemoral joints that had patella alta and/or dysplastic bone anatomy. These results indicate that the patellar realignment brace was able to counteract patellar subluxation in the majority of patellofemoral joints studied, as shown by active-movement, loaded kinematic MR imaging. This brace appears to be useful for conservative treatment of patients with patellofemoral joint pain secondary to patellar malalignment and maltracking.     

Clinical comments on management of urosepsis in a general urological department.

Over a period of 6 years 192 cases of urosepsis have been recorded and managed in our urological department. In almost all cases (97%) the primary focus of infection was the urinary tract and the responsible microorganisms were Gram-negative rods, in order Enterobacter, B. Proteus, E. Coli, Klebsiella and others. Clinical features were dominated by symptoms related to failure or insufficiency of end organs (fever, hypotension, oliguria, mental disorders, respiratory distress etc.). Bacteremia was diagnosed with an incidence of 66%, septic shock 12% and MSOF 20%. Negative bacteriological tests do not rule out the diagnosis of systemic infection. Risk factors are considered advanced age, uremia, diabetes, malnutrition and extensive surgery.     

A new device for the identification of lymph nodes at lung cancer surgery.

In order to provide a precise lymph node mapping during lung cancer surgery a sterilizable plastic tray moulded in the shape of the mediastinum and lungs is presented by the author. The device makes lymph node mapping simpler, safer, quicker and methodically more structured. A positive impact is expected as a result of usage of the device from making pathologist's work easier and facilitating the flux of information on the surgeon-pathologist-oncologist-pneumonologist chain to be more disinformation-free.     

Current surgical treatment of thoracic empyema in adults.

A review of the recent literature on treatment modalities of adult thoracic empyema was conducted in order to expose the controversies and verify where consensus exists. Critical reading filtered through clinical experience was the method followed. The roles of surgical drainage, lavage techniques, debridement via VATS, decortication, thoracoplasty and open window thoracostomy were considered using the Oxford Center of Evidence Based Medicine criteria. The roles of the different therapeutical modalities were interpreted in the light of the triphasic nature of empyema thoracis. The randomised controlled trials came up with conflicting results. With two exceptions all of the papers reviewed provide level (2b) or below evidences. The lack of a single ideal treatment modality or policy reflects the complexity of the diagnosis and staging of this heterogeneous disease. Basic elements of intervention--drainage, different evacuation techniques, decortication, thoracoplasty and open window thoracostomy--are well-established technical modalities; however, neither a universally acceptable primary modality nor the gold standard of their sequence is available. Drainage remains to be the initial treatment modality in Phase I disease. Debridement via VATS is a safe, reliable and efficient method in the fibrinopurulent phase. Organised pleural callus requires formal decortication. Open window thoracostomy is a simple and safe procedure for high-risk patients and results in quick detoxication. Thoracoplasty kept its final role in pleural space management. Acute postoperative bronchial stump insufficiency requires immediate surgery. Evacuation of toxic material is mandatory. No single-stage procedure offers a solution. An optimised agressivity treatment modality should be tailored to the condition of the patient and to the potential of the persisting cavity. Decision-making involves a triad consisting of the aetiology of empyema (i.e. primary vs secondary), general condition of the patient and stage of disease, while considering the triphasic nature of development of thoracic empyema. The current attitudes show that the present concepts are based mainly on expert opinion. Flexibility and patience on behalf of the surgeon and nursing staff, the patient and the hospital management, as well as a good understanding of the complexity of this condition are the cornerstones of the treatment. No exclusive sequence of procedures leading to a uniformly predictable successful outcome is available. Individualised approaches can be recommended based on institutional practice and local protocols. Thoracic empyema in general seems to remain resilient to fit completely into the categories of evidence-based medical approach.     

New light on uveitis in ankylosing spondylitis

Inflammatory eye disease is well recognized in ankylosing spondylitis (AS) but the relationship between the uveitis and the spondyloarthropathy is poorly defined. The following conclusions may be drawn from a study of 1331 consecutive patients with AS: the prevalence of uveitis was 40% (535 subjects), almost half of whom had greater than 5 attacks. Family studies of sib pairs, concordant for AS, showed that uveitis occurred randomly with a concordance for uveitis/no uveitis of only 43%. A comparison of patients with (n = 535) and without (n = 796) uveitis showed no important differences. Analysis of potential trigger factors among 72 patients with recurrent disease revealed no seasonal, infective or other correlation. The removal of an intrauterine device from a woman with severe intractable bilateral uveitis was associated with remission of the eye disease. In summary, although genetic background determines susceptibility to uveitis the pattern of the disease suggests the possibility of random environmental triggers unrelated to the course of the underlying rheumatological disorder.     

The influence of age, height, and body weight on cerebrospinal fluid amine metabolites and tryptophan in women

Cerebrospinal fluid 5-hydroxyindoleacetic acid (CSF 5HIAA), homovanillic acid, and tryptophan were measured in 33 depressed, 36 alcoholic, and 32 neurological control female patients selected by strict operational criteria and investigated under controlled circumstances. Plasma total tryptophan was also measured in blood samples taken simultaneously with lumbar punctures. A multivariate regression analysis was done to discover the effect of age, height, and body weight on these four biochemical measures. Only CSF 5HIAA was significantly dependent on the nonspecific patient variables: height, but neither age nor weight, accounted for more than 10% of the variance of 5HIAA. The same analysis was carried out in all three separate patient groups: the relationship between height and CSF 5HIAA was present throughout, and only 2 of 12 correlations proved to be non-homogeneous. To demonstrate the significantly of these clinical parameters a multivariate analysis of covariance was done to eliminate their effect on the four biochemical variables. As a result significant differences emerged in CSF 5HIAA and total plasma tryptophan for some of the patient groups which were not demonstrable without this correction.     

Measurement of subclinical changes during lithium prophylaxis: a longitudinal study

Psychological distress was observer-rated with the Brief Psychiatric Rating Scale (BPRS) and self-rated with the Symptom Questionnaire (SQ) every other week for a 6-month period in 9 apparently remitted bipolar patients attending a lithium clinic. Substantial clinical fluctuations in psychopathology were observed with both rating methods. Compared to normal control subjects, patients suffering from bipolar disorder displayed significantly higher BPRS and SQ anxiety, somatization and total distress scores.