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We examined relationships between measures of total knee arthroplasty (TKA) “appropriateness” constructs and surgeon TKA recommendations in people with knee osteoarthritis (OA). Although TKA is highly effective, fifteen to thirty percent of recipients report dissatisfaction and/or little or no symptom improvement. More appropriate selection of surgical candidates may improve both patient outcomes and healthcare resource use, but no validated appropriateness criteria exist currently in Canada.
Patients 30 years of age or older with knee OA referred for surgical consultation at two large joint arthroplasty centres in Alberta, Canada were invited to participate. Participants completed a standardized pre-consult questionnaire, which included the following sociodemographics and validated measures of appropriateness constructs for TKA: knee symptoms; non-surgical management; patient readiness for and expectations of TKA; and net patient benefit. Post-consultation, surgeons were asked to confirm knee OA and their recommendation. We used multivariable logistic regression to examine the relationship between measures of appropriateness constructs and receipt of surgeon TKA recommendation.
Of 3,009 patients approached, 2,360 completed the questionnaire and 2,064 (sixty-nine percent) were eligible at surgical consultation (mean age 65.7 years, standard deviation 9.1; fifty-nine percent were women); 1,495 (seventy-two percent) were recommended for TKA. The likelihood of receiving a TKA recommendation was independently associated with: knee symptoms (odds ratio [OR] per unit increase in pain intensity, 1.19 (95% confidence interval [CI]: 1.11–1.27)); prior non-surgical OA management (OR for prior knee injection, 1.53 (95% CI: 1.21–1.94)); readiness for surgery (OR if definitely/probably willing to undergo TKA, 3.03 (95% CI: 1.99–4.59)); and TKA expectations (OR outcome “very important”: ability to perform daily activities, 1.40 (95% CI: 1.04–1.88); straighten the knee/leg 1.42 (95% CI: 1.13–1.80); participate in exercise/sports 0.75 (95% CI: 0.58–0.98)).
In our cohort of patients with confirmed knee OA who consulted a surgeon for TKA, appropriateness constructs were significantly associated with receipt of a TKA recommendation. Research is ongoing to evaluate the predictive validity of these measures for patient-reported outcomes associated with TKA.
A predictive risk stratification tool (PRISM) to estimate a patient's risk of an emergency hospital admission in the following year was trialled in general practice in an area of the United Kingdom. PRISM's introduction coincided with a new incentive payment (‘QOF’) in the regional contract for family doctors to identify and manage the care of people at high risk of emergency hospital admission.
Alongside the trial, we carried out a complementary qualitative study of processes of change associated with PRISM's implementation. We aimed to describe how PRISM was understood, communicated, adopted, and used by practitioners, managers, local commissioners and policy makers. We gathered data through focus groups, interviews and questionnaires at three time points (baseline, mid-trial and end-trial). We analyzed data thematically, informed by Normalisation Process Theory (1).
All groups showed high awareness of PRISM, but raised concerns about whether it could identify patients not yet known, and about whether there were sufficient community-based services to respond to care needs identified. All practices reported using PRISM to fulfil their QOF targets, but after the QOF reporting period ended, only two practices continued to use it. Family doctors said PRISM changed their awareness of patients and focused them on targeting the highest-risk patients, though they were uncertain about the potential for positive impact on this group.
Though external factors supported its uptake in the short term, with a focus on the highest risk patients, PRISM did not become a sustained part of normal practice for primary care practitioners.
New approaches are needed to safely reduce emergency admissions to hospital by targeting interventions effectively in primary care. A predictive risk stratification tool (PRISM) identifies each registered patient's risk of an emergency admission in the following year, allowing practitioners to identify and manage those at higher risk. We evaluated the introduction of PRISM in primary care in one area of the United Kingdom, assessing its impact on emergency admissions and other service use.
We conducted a randomized stepped wedge trial with cluster-defined control and intervention phases, and participant-level anonymized linked outcomes. PRISM was implemented in eleven primary care practice clusters (total thirty-two practices) over a year from March 2013. We analyzed routine linked data outcomes for 18 months.
We included outcomes for 230,099 registered patients, assigned to ranked risk groups.
Overall, the rate of emergency admissions was higher in the intervention phase than in the control phase: adjusted difference in number of emergency admissions per participant per year at risk, delta = .011 (95 percent Confidence Interval, CI .010, .013). Patients in the intervention phase spent more days in hospital per year: adjusted delta = .029 (95 percent CI .026, .031). Both effects were consistent across risk groups.
Primary care activity increased in the intervention phase overall delta = .011 (95 percent CI .007, .014), except for the two highest risk groups which showed a decrease in the number of days with recorded activity.
Introduction of a predictive risk model in primary care was associated with increased emergency episodes across the general practice population and at each risk level, in contrast to the intended purpose of the model. Future evaluation work could assess the impact of targeting of different services to patients across different levels of risk, rather than the current policy focus on those at highest risk.
Emergency admissions to hospital are a major financial burden on health services. In one area of the United Kingdom (UK), we evaluated a predictive risk stratification tool (PRISM) designed to support primary care practitioners to identify and manage patients at high risk of admission. We assessed the costs of implementing PRISM and its impact on health services costs. At the same time as the study, but independent of it, an incentive payment (‘QOF’) was introduced to encourage primary care practitioners to identify high risk patients and manage their care.
We conducted a randomized stepped wedge trial in thirty-two practices, with cluster-defined control and intervention phases, and participant-level anonymized linked outcomes. We analysed routine linked data on patient outcomes for 18 months (February 2013 – September 2014). We assigned standard unit costs in pound sterling to the resources utilized by each patient. Cost differences between the two study phases were used in conjunction with differences in the primary outcome (emergency admissions) to undertake a cost-effectiveness analysis.
We included outcomes for 230,099 registered patients. We estimated a PRISM implementation cost of GBP0.12 per patient per year.
Costs of emergency department attendances, outpatient visits, emergency and elective admissions to hospital, and general practice activity were higher per patient per year in the intervention phase than control phase (adjusted δ = GBP76, 95 percent Confidence Interval, CI GBP46, GBP106), an effect that was consistent and generally increased with risk level.
Despite low reported use of PRISM, it was associated with increased healthcare expenditure. This effect was unexpected and in the opposite direction to that intended. We cannot disentangle the effects of introducing the PRISM tool from those of imposing the QOF targets; however, since across the UK predictive risk stratification tools for emergency admissions have been introduced alongside incentives to focus on patients at risk, we believe that our findings are generalizable.
Postinjection delirium/sedation syndrome (PDSS) has been reported uncommonly during treatment with olanzapine long-acting injection (LAI), a sustained-release formulation of olanzapine.
The primary aim of the study was to estimate the incidence per injection and per patient of PDSS events in adult patients with schizophrenia who were receiving olanzapine LAI in real-world clinical practice. Secondary aims were to further characterise the clinical presentation of PDSS events, to identify potential risk factors associated with PDSS events and to characterise hospitalisations at baseline and post-baseline.
A prospective observational study of adult patients with schizophrenia receiving olanzapine LAI from 24 countries. Data were collected on patient characteristics, olanzapine LAI treatment and any adverse events (AEs). All AEs were reviewed and adjudicated for PDSS using predetermined criteria.
There were 46 confirmed PDSS events (0.044% of the 103 505 injections) in 45 patients (1.17% of the 3858 patients). Based on 45 confirmed events with time-to-onset information, 91.1% (n=41) occurred within 1 h of injection. Time-to-recovery from the event was within 72 h for 95.6% of patients (range 6 h to 11 days). Risk factors for PDSS (per-injection) included high dose (odds ratio (OR)high/low=3.95; P=0.006) and male gender (ORfemale/male=0.42; P=0.017).
Results of this study confirm previously reported PDSS rates, time to onset and recovery, and the severity of PDSS events, and suggest that higher doses and male gender are potential risk factors associated with PDSS.
A robust collection of mammal, bird, fish, and shellfish remains from an 8,000-year residential sequence at Morro Bay, a small, isolated estuary on the central California coast, shows a strong focus on marine species during the Middle-Late Transition cultural phase (950–700 cal B.P.), which largely coincides with the Medieval Climatic Anomaly (MCA). Previous studies have provided modest evidence for increased fishing and rabbit hunting during the MCA in adjacent regions, but the Morro Bay findings suggest a distinctive marine-focused subsistence refugium during the period of drought. Specifically, the sequence shows striking all-time peaks in marine and estuarine birds, fish NISP/m3, and fish/deer + rabbits during the MCA. Heavy exploitation of fish, aquatic birds, rabbits, and shellfish suggests that the bow and arrow, which seems to have arrived in the area at this time, had little impact on local subsistence strategies.
Our Constitution established a federal system that embraces both autonomous states and a strong national government. Preserving that constitutional scheme has challenged the Supreme Court since its earliest days. As Chief Justice John Roberts recently recognized, “the path of” the Court’s federalism jurisprudence “has not always run smooth.” That path has been particularly jagged during recent years. In a series of high-profile cases, the Court has undercut both national authority and state autonomy; the results defy both the Constitution and any principled view of federalism.
Justice Ruth Bader Ginsburg has repeatedly dissented from these decisions, articulating a coherent view of federalism that honors both national power and state autonomy. Justice Ginsburg’s opinions draw upon federalism principles that the Court forged during the middle decades of the twentieth century; this is the federalism that prevailed before the muddled federalism “revolution” of the Rehnquist and Roberts Courts.
Justice Ginsburg, however, has rei ned those twentieth-century doctrines, giving them a voice of her own. As the Court’s most persistent and articulate dissenter in federalism cases, she has crafted a nuanced vision of federal-state relations that serves the Constitution, national interests, and the continued vitality of state governments.
This chapter explores several of Justice Ginsburg’s most notable federalism opinions. Part one examines representative cases in which Justice Ginsburg recognized Congress’s power to legislate in the national interest.
The present study examined the impact of children's maltreatment experiences on the emergence of externalizing problem presentations among children during different developmental periods. The sample included 788 youth and their caregivers who participated in a multisite, prospective study of youth at-risk for maltreatment. Externalizing problems were assessed at ages 4, 8, and 12, and symptoms and diagnoses of attention-deficit/hyperactivity disorder, oppositional defiant disorder, and conduct disorder were assessed at age 14, during interviews with youth and caregivers. Information about maltreatment allegations was coded from official records. Latent transition analysis identified three groups of youth with similar presentations of externalizing problems (“well adjusted,” “hyperactive/oppositional,” and “aggressive/rule-breaking”) and transitions between groups from ages 4, 8, and 12. A “defiant/deceitful” group also emerged at age 12. Girls were generally more likely to present as well adjusted than boys. Children with recent physical abuse allegations had an increased risk for aggressive/rule-breaking presentations during the preschool and preadolescent years, while children with sexual abuse or neglect allegations had lower probabilities of having well-adjusted presentations during middle childhood. These findings indicate that persistently severe aggressive conduct problems, which are related to the most concerning outcomes, can be identified early, particularly among neglected and physically and sexually abused children.
Cogongrass invades forests through rhizomatous growth and wind-dispersed seeds. Increased density and abundance of woody vegetation along forest edges may strengthen biotic resistance to invasion by creating a vegetative barrier to dispersal, growth, or establishment of cogongrass. We evaluated differences in dispersal of cogongrass spikelets experimentally released from road edges into tallgrass-dominated and shrub-encroached longleaf pine forests (Pinus palustris). Average maximum dispersal distances were greater in the pine–tallgrass forest (17.3 m) compared to the pine–shrub forest association (9.4 m). Spikelets were more likely to be intercepted by vegetation in pine–shrub forests compared to pine–tallgrass forests. Results suggest that dense woody vegetation along forest edges will slow spread from wind-dispersed cogongrass seeds.
Single source precursors which contain preformed gallium-nitrogen and aluminum-nitrogen bonds are being considered for the growth of gallium and aluminum nitride because of their potential for overcoming problems associated with conventional precursors. Presented is the evaluation of dimethylgallium azide, Me2GaN3(1), bisdimethylamidogallium azide, (Me2N)2GaN3(2), and bisdimethylamidoaluminum azide, (Me2N)2AlN3(3) as potential precursors for A1N and GaN film growth. The compounds were evaluated for stability, ease of transport, temperature of decomposition and quality of film deposited. Amorphous thin films of GaN with a band gap of 3.4 eV were deposited with 2 at 250 °C. Increasing the substrate temperature to 580 °C resulted in the deposition of epitaxial GaN films. Polycrystalline A1N films were grown with 3 at 600 °C.
Due to its low resistivity and excellent thermal stability, IrO2 has attracted attention as an alternative for electrode material in ferroelectric integrated circuit applications. In this work, IrO2 films deposited using reactive DC magnetron sputtering were studied. Film properties such as resistivity, crystallinity and morphology were examined as a function of deposition condition. Optimum process parameters to obtain high quality IrO2 thin films are suggested.
The correlation between the dielectric constant and dispersion is investigated for barium strontium titanate (BST) capacitors with platinum and iridium electrodes. For platinum electrode capacitors, dispersion decreases with increasing dielectric constant. In contrast, capacitors with iridium electrodes exhibit the reverse correlation. A simple model is proposed to provide a quantitative explanation for the observed correlation for both platinum and iridium electrodes. In addition, the dependence of the dielectric constant and dispersion on varying ratios of (Ba+Sr)/Ti is also reported.