2 Minute Medicine Rewind February 11, 2019

Factors associated with unplanned reoperation after above-knee amputation

Unplanned reoperation is a significant source of morbidity and mortality in patients that have undergone above-knee amputation (AKA). While there are certain unifying features to this patient population, namely significant underlying vascular disease, the authors of this study aimed to identify risk factors for unplanned reoperation after AKA. In this retrospective cohort study, 185 AKA operations were performed in 155 patients. Researchers found that there was a 15.7% rate of unplanned reoperation, most often for a soft tissue wound revision (48%), followed by re-amputation with a more proximal osteotomy (45%) and hip disarticulation (7%). Independent risk factors for reoperation after multivariate regression included prior ipsilateral revascularization (OR 4.43, 95% CI 1.45 to 13.45, p=0.009), multiple indications for amputation (OR 6.44, 95% CI 1.52 to 27.32, p=0.01), postoperative hematoma formation (OR 17.82, 95% CI 1.41 to 22.68, p=0.02) and wound dehiscence (OR 7.99, 95% CI 1.88 to 36.87, p=0.005). Interestingly, reoperation was not associated with an increase in overall mortality in this study. In addition, neither anticoagulation nor serum albumin was found to be associated with reoperation. This study therefore shows that patients with wound complications are at the highest risk of reoperation after AKA. This study was limited in that there was a paucity of data surrounding patient metabolic risk factors, which may have also contributed to the risk of complications after the index surgery. Further research is needed to identify individuals at risk of experiencing wound complications.

US National and State-Level Prevalence of Mental Health Disorders and Disparities of Mental Health Care Use in Children

The impact of a child’s mental health on individual and socioeconomic factors, and ultimately, transition to adulthood, is becoming increasingly more recognized. As such, with an increasing incidence of mental health disorders amongst children, numerous initiatives have emerged with the aim of identifying priority focus areas regarding mental health-related burden; this includes reducing disparities for mental healthcare use. In this retrospective cohort study, data from the 2016 National Survey of Children’s Health was used to estimate the prevalence of treatable mental health disorders and mental healthcare use in children. An estimated 46.6 million children were included for the analysis. Researchers found that the national prevalence of at least 1 mental health disorder as 16.5% (weighted estimate, 7.7 million). After adjustment, all covariates, except for continuous insurance were found to be associated with mental health disorders. These covariates included ages 12-17 years (OR 1.65, 95% CI 1.44 to 1.89), male sex (OR 1.31, 95% CI 1.14 to 1.49), Non-Hispanic white ethnicity (OR 1.90, 95% CI 1.51 to 2.39), poverty status, single parent (OR 1.40, 95% CI 1.19 to 1.65), and a lack of a medical home (OR 1.31, 95% CI 1.15 to 1.49). The national prevalence of children with a mental health disorder who did not receive needed treatment or counseling from a mental health professional was 49.4%, ranging from 29.5% (Washington, DC) to 72.2% (North Carolina). This study therefore shows that nearly half of the estimated 7.7 million children in the US with a treatable mental health disorder did not receive needed treatment from a mental health professional, with considerable variability between states. This has important implications for state-level practices and policies impacting access to these needed healthcare services.

Arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of symptomatic femoroacetabular impingement: multicentre randomised controlled trial

Patients with femoroacetabular impingement (FAI) have a predisposition towards premature joint degeneration. While physiotherapy and modified activity represents the principal treatment for symptomatic FAI, arthroscopic surgery is being increasingly adopted as part of reshaping the hip joint, managing damage to the labrum and cartilage, and improving pain and function. The efficacy of hip surgery for this indication, however, has not been well studied. In this randomized controlled trial, 222 patients age 18 to 60 years with symptomatic FAI were randomized to receive arthroscopic hip surgery or a program of physiotherapy and activity modification to compare these interventions in terms of their improvement in patient-reported outcomes, specifically activities of daily living at 8 months of follow-up. Researchers found that the mean hip outcome score activities of daily living subscale (HOS-ADL) in the arthroscopic surgery group was 10.0 points (95% CI 6.4 to 13.6) higher than that seen in the physiotherapy group at 8 months post-randomization. Clinically important improvement within the individual, defined as an increase in HOS-ADL of at least 9 points, was reported in 51% of participants allocated to the arthroscopic surgery group and 32% of participants in the physiotherapy group. The proportion of patients who achieved their expectation in terms of HOS-ADL at follow-up was 31% in the arthroscopic group compared to 15% in the physiotherapy group. This study therefore shows that arthroscopic hip surgery likely results in superior outcomes in terms of activities of daily living and physical functioning in FAI patients when compared to non-interventional approaches including physiotherapy. Further research is needed to identify patients most likely to benefit from such an intervention.

The effect of a programme to improve men’s sedentary time and physical activity: The European Fans in Training (EuroFIT) randomised controlled trial

The World Health Organization (WHO) recommends that individuals participate in at least 150 minutes per week of moderate-to-vigorous physical activity, as part of the prevention of chronic diseases, including cardiovascular disease, type 2 diabetes and several cancers. Nearly one third of adults, however, fail to meet these recommendations. Sedentary behaviour has been found to be associated with all-cause mortality and cardiovascular mortality, independent of physical activity. In this multinational randomized controlled trial, 1,113 men age 30 to 65 years with a body mass index (BMI) ³27 were randomized to participate in a 12-week, group-based program (EuroFIT) or a 12-month waiting list comparison group to evaluate the effectiveness of such an intervention in increasing physical activity and decreasing sedentary time over a 12-month period. Coaches in football club stadia delivered the intervention program in 12 weekly 90-minute sessions. Uniquely, EuroFIT uses the allegiance many fans have to their football club to attract at-risk men to a group-based lifestyle change programme delivered in their clubs. Researchers found that the individuals in the intervention group had a higher mean daily step count at 12 months compared to the control group (estimated difference 678 steps/day, 97.5% CI 309 to 1048, p<0.001). There was no evidence of a difference in sedentary time (p=0.77). Interestingly after the completion of the program, larger between-group differences in step counts were observed (estimated difference 1208 steps/day, 97.5% CI 869 to 1546). This was in addition to significant decreases in sedentary time (estimated difference -14.4 minutes/day, 95% CI -25.1 to -3.8). Mean body weight, BMI, waist circumference and the proportion of participants with BMI ³30 all improved significantly in the intervention group when compared to the control group (p<0.001 for all). Improvements in cardiovascular risk biomarkers was also seen at 12 months, including improvements in systolic (p=0.047) and diastolic blood pressure (p=0.004), fasting insulin (p<0.001), fasting triglycerides (p=0.006), ALT (p=0.004) and GGT (p=0.003) concentrations. This study therefore shows that participation in the EuroFIT program led to improvements in physical activity, body weight and biomarkers of cardiometabolic health, but not in sedentary time at 12 months.

Assessment of application-driven postoperative care in the pediatric tonsillectomy population: a survey-based pilot study

Parents typically receive written postoperative instructions for children that have recently undergone pediatric tonsillectomy. While the usefulness of disseminating postoperative information via paper instructions has not been studied, in an era of increasing productivity and usability related to smart device-based applications (apps), the authors of this study aimed to assess the usability and reception of postoperative information and/or instructions disseminated via a smartphone format. Of the 53 families able to provide data via telephone, researchers found that 68% used the app, and that 89% of app-users preferred the app to traditional paper-based instructions. Families that did not use the app indicated that they had forgot to download the app or did not any postoperative instructions. Of the families contacted (non-app users included), 31% of families called the clinic to discuss postoperative care; 22% of families who used the smartphone app contacted the clinic. A greater proportion of parents referenced the app more than 3 times versus the paper instructions (absolute difference 0.36, 95% CI 0.164 to 0.515). A greater proportion of parents graded the smartphone app as “very helpful” (absolute difference 0.250, 95% CI 0.083 to 0.404) and “very ease to use” (absolute difference 0.330, 95% CI 0.172 to 0.467) when compared to paper instructions. This study demonstrated that families responded positively to patient-clinician communication via a smartphone medium, with indicators of increased ease of use of finding information.

Image: PD

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