The effect of age on pain, function, and quality of life after total hip and knee arthroplasty

BACKGROUND

As utilization rates for total joint arthroplasty increase, there is a hesitancy to perform this surgery on very old patients. The objective of this prospective study was to compare pain, functional, and health-related quality-of-life outcomes after total hip and total knee arthroplasty in an older patient group (> or =80 years) and a representative younger patient group (55-79 years).

METHODS

In an inception community-based cohort within a Canadian health care system, 454 patients who received primary total hip arthroplasty (n = 197) or total knee arthroplasty (n = 257) were evaluated within a month prior to surgery and 6 months postoperatively. Pain, function, and health-related quality of life were evaluated with the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index and the 36-Item Short-Form Health Survey (SF-36).

RESULTS

There were no age-related differences in joint pain, function, or quality-of-life measures preoperatively or 6 months postoperatively. Furthermore, after adjusting for potential confounding effects, age was not a significant determinant of pain or function. Although those in the older and younger groups had comparable numbers of comorbid conditions and complications, those in the older group were more likely to be transferred to a rehabilitation facility than younger patients. Regardless of age, patients did not achieve comparable overall physical health when matched with the general population for age and sex.

CONCLUSIONS

With increasing life expectancy and elective surgery improving quality of life, age alone is not a factor that affects the outcome of joint arthroplasty and should not be a limiting factor when considering who should receive this surgery.

Imaginal flooding and exposure to real phobic situations: treatment outcome with agoraphobic patients

Each of thirty-six female agoraphobic out-patients were treated by one of three methods: 8 sessions of imaginal flooding followed by 8 sessions of practice in the real situation; 16 sessions of combined flooding and practice; or 16 sessions of practice alone. Three therapists treated equal numbers of patients in each group, and there was some evidence that patients' response varied according to the therapist seen, irrespective of treatment group. There were no significant differences between treatment groups after 8 sessions, 16 sessions or on six-month follow-up. It is concluded that there are no long-term differences between the effects of treatments involving exposure to either imaginal or real phobic situations or to a combination of both, provided that patients are encouraged to practise between sessions.

Erythropoietin with iron supplementation to prevent allogeneic blood transfusion in total hip joint arthroplasty. A randomized, controlled trial

BACKGROUND

The optimum regimen of epoetin alfa for prevention of allogeneic blood transfusion is unknown.

OBJECTIVE

To determine whether a modified regimen of epoetin alfa reduces allogeneic blood transfusion in patients undergoing hip arthroplasty.

DESIGN

Randomized, double-blind, multicenter trial comparing two modified dose regimens of epoetin alfa with placebo.

SETTING

13 teaching hospitals and 4 community hospitals in Canada.

PATIENTS

201 patients undergoing primary hip arthroplasty who had a hemoglobin concentration of 98 to 137 g/L and did not predonate blood.

INTERVENTION

Patients were assigned in a 3:5:5 ratio to receive four weekly doses of epoetin alfa, 40 000 U (high-dose; n = 44) or 20 000 U (low-dose; n = 79), or placebo (n = 78), starting 4 weeks before surgery. All patients received oral iron supplementation, 450 mg/d, for 42 or more days before surgery.

MEASUREMENTS

The primary end point was allogeneic transfusion. Secondary end points were thromboembolic events and change in reticulocyte count and hemoglobin concentration.

RESULTS

Both modified epoetin alfa regimens significantly reduced the need for allogeneic transfusion: Five (11.4%) patients in the high-dose group (P = 0.001) and 18 (22. 8%) patients in the low-dose group (P = 0.003) had transfusion, compared with 35 (44.9%) patients in the placebo group. The hematologic response was substantial in patients who received epoetin alfa. In the high-dose group, low-dose group, and placebo group, the preoperative increase in reticulocyte count was 58.8, 37. 0 and 1.8 x 10(9) cells/L (P < 0.001), respectively, and the increase in hemoglobin concentration was 19.5, 17.2, and 1.2 g/L (P < 0.001). The incidence of thromboembolic events did not differ among groups.

CONCLUSIONS

Both modified epoetin alfa regimens were effective compared with placebo in reducing allogeneic transfusion in patients undergoing hip arthroplasty. Patients who received high-dose epoetin alfa had the lowest transfusion rate.

Specific and non-specific factors in behaviour therapy

Previous investigations have suggested that desensitization is the treatment of choice for simple phobic disorders, but is less effective with agoraphobia, particularly when the phobias are accompanied by much generalized anxiety (Gelder and Marks, 1966). Even the milder agoraphobias usually respond incompletely despite prolonged treatment. An alternative treatment that offers more rapid or effective results, particularly with agoraphobia, would therefore be of value. The technique of flooding or implosion has recently been the subject of a number of studies, and some, but not all, have shown evidence of considerable therapeutic power. The method is also of some theoretical interest since it breaks the rules which are thought to be important in desensitization. Thus, according to early proponents (Stampfl and Levis, 1967) success depends on exposing patients to fantasy material of an extremely intense and anxiety-provoking nature, so that extinction to cues associated with the original traumatic situation may take place. From this theoretical viewpoint desensitization can be only partially successful, since these traumatic origins are neither sought for nor presented to the patient. Even if the necessity of dealing with original anxiety-provoking cues is not accepted, the use of material which evokes maximal anxiety for prolonged periods is contrary to the counter-conditioning theory of desensitization (Wolpe, 1958). Indeed, this theory predicts that flooding would rarely be successful and might make the phobia worse because uncontrolled increases in anxiety may cause reconditioning.

Distress, stress and coping in first-year student nurses

Levels of affective distress, sources of stress and coping strategies reported by first-year student nurses in Tayside, Scotland, were measured using the General Health Questionnaire (30-item version), the Beck & Srivastava Stress Inventory (BSSI) and a modified 'Ways of Coping Questionnaire'. Screening showed that, around the time of an initial series of hospital placements, 50.5% of students in cohort 1 (n = 109, week 40) and 67.9% of students in cohort 2 (n = 111, week 24) suffered significant affective distress. This exceeds levels reported in published studies of degree nursing students, fourth-year medical students, and the general female population. Distressed students reported the same sources of stress as the non-distressed students, but suffered them more intensely. Many BSSI items were seen as common sources of stress; however, the frequency with which an item was reported to be stressful was not related to whether scores on that item predicted overall distress. In both cohorts, the use of direct coping was associated with lower levels of distress, and with lower total stress scores on the BSSI. The use of fantasy and hostility was associated with high levels of distress and stress, in both groups. This screens of 220 first-year student nurses suggests that there is a problem with student distress around an initial series of general/surgical and psycho-social ward placements. The possible determinants of this distress and complex, and it is unlikely that presenting information alone will be sufficient to reduce this distress.

Fractures of the tibial plateau: a review of ninety-five patients and comparison of treatment methods

Ninety-five patients with fractures of the tibial plateau have been reviewed. The fractures were grouped, according to the X-ray pattern, into five fracture types. Treatment was grouped into plaster immobilization or traction in the conservative group, and open reduction with internal fixation, open reduction with bone grafting, or open reduction with internal fixation and bone grafting in the operated group. It was concluded from this review that tibial plateau depression or tibial plateau widening of less than 10 mm was usually tolerated well and did not preclude a successful result. Adequacy of reduction was a least as important as early motion in obtaining a satisfactory result regardless of the type of fracture treated. If open reduction is undertaken both internal fixation and bone grafting are required in the most common types of these fractures. The exceptions are Type I or split fractures which do not require a bone graft and Type III or central depression fractures which do not require internal fixation.

A biomechanical comparison of various methods of stabilization of subtrochanteric fractures of the femur

Subtrochanteric femoral fractures with and without bony contact were simulated in cadaver specimens, fixed with one of seven different types of intramedullary or plate implants, and tested biomechanically. The implants used were Enders pins, Zickel nail, compression hip screw, AO angled blade plate, and intramedullary locked nail systems of the Klemm-Schellman, Brooker-Wills, and Grosse-Kempf types. Femur-implant constructs using intramedullary devices were a maximum of 5% as stiff in torsion as intact cadaveric femora tested in the same manner, while plate-fixed fractures were nearly 50% as stiff. In bending, all devices except the Enders pins were approximately 80% as stiff as intact femora. Loss of bony contact at the fracture site had little effect on stiffness except in the case of the keyless compression hip screw, where the screw rotated freely in the barrel. In combined bending and compression to failure, a test to simulate forces due to body weight, the intramedullary locked rods were found to support between 300 and 400% of body weight while the plate systems failed at loads between 100 and 200% of body weight.

Impact on patients and partners of inpatient and extended cardiac counseling and rehabilitation: a controlled trial

OBJECTIVES

This study evaluated the effectiveness of cardiac counseling and rehabilitation programs led by a nurse counselor, compared with normal care on outcomes for myocardial infarction (MI) patients and their partners.

METHODS

A randomized controlled trial with follow-up to 1 year was conducted with 100 patients recruited within 72 hours of a first MI and their partners: a Control group received normal care; an Inpatient group received cardiac rehabilitation from a nurse counselor while in hospital; and an Extended group received the same cardiac rehabilitation as the Inpatient group, but with additional sessions continuing up to 6 weeks after discharge from hospital. The scales for main outcome measures were 1) knowledge of heart disease and treatment (correct, misconceptions, and uncertainty); 2) mood (Hospital Anxiety and Depression Scale); 3) satisfaction; 4) disability (Functional Limitations Profile).

RESULTS

Inpatient cardiac counseling and rehabilitation resulted in more knowledge, less anxiety, less depression, and greater satisfaction with care in both patients and partners and in less disability in patients, with effects enduring to 1 year. There was some evidence of additional benefit from the Extended program. Both nurse counselors achieved benefits on all outcome variables.

CONCLUSIONS

This Inpatient cardiac counseling and rehabilitation program resulted in significant and enduring benefits of clinical value. It is likely that it would be acceptable to most post-MI patients, many of whom are not offered or are unable to accept outpatient cardiac rehabilitation.

Reducing distress in first level and student nurses: a review of the applied stress management literature

Following recent evidence of continuing high levels of distress in both trained and student nurses, a critical review of the stress reduction and stress management literature targeting both trained and student nurses is presented. Using a systematic approach, some 36 studies dating from 1980 until the present day were identified adopting either pre-experimental, quasi-experimental or experimental designs. While many work-site programmes in this series were successful in terms of adaptive changes in problem-solving, self-management skills including relaxation and interpersonal skills, affective well-being, and work performance, a number of design and evaluation inadequacies were identified. The relative lack of home-work interface or organizational level programmes to reduce work-related distress, and the scarcity of interventions targeting aspects of the work environment likely to contribute to such outcomes may have contributed to continuing high levels of distress in trained and student nurses. Recommendations regarding the future design, provision and evaluation of such work-site interventions include the further clarification of the structure of perceived stressors, and development of causal models of the stress process to identify the job characteristics 'causing' work-related distress. Such an approach would inform the design and implementation of evidence-based organizational level interventions augmenting strategies to target the health behaviour, lifestyle/risk factors and self-management skills of practitioners and students with attempts to amend problematic elements of the psychosocial work environment.

The relationship between cardiovascular responses in the laboratory and in the field

The psychophysiological responses to laboratory stressors are often examined because it is believed that such responses relate to responsiveness in real life situations. This belief has seldom been tested. The changes in heart rate, pulse transit time, and respiration rate produced by a variety of laboratory tasks (active and passive coping and physical exercise) were related to ambulatory measures of heart rate in 32 young men. The field measures were the difference in heart rate between the waking day and when asleep, and estimates of the variability of heart rate during the day, derived from time series analyses. Average changes in heart rate and pulse transit time during specific tasks did not relate consistently to heart rate in the field. However, an active coping index, derived from the ratio of the peak heart rate during an active coping task to the peak during physical exercise related to all the field measures of heart rate responsiveness. This index, which may relate to measures of additional heart rate and heightened sympathetic response to stress, also correlated positively with Trait Anxiety and elevated basal sympathetic arousal, as measured by skin conductance level. Measures of the cardiovascular response to a passive coping task, the cold pressor, and exercise did not relate to heart rate responses in the field. The findings suggest that heightened cardiac responsiveness in real life is exhibited by subjects who show elevated peak responses to active coping stressors specifically.

Agoraphobia: the long-term follow-up of behavioural treatment

Sixty-six agoraphobic patients were followed up five to nine years after their treatment in three clinical trials of behaviour therapy. The main outcome measures used in the original trials were repeated by an assessor who interviewed the patients. Ninety-five per cent of patients were interviewed and partial information was obtained on a further two patients. The measures taken at follow-up were compared with those obtained prior to treatment and six months after treatment ended. On most measures of agoraphobia the patients were much better at follow-up than they had been before treatment. The assessor's ratings suggested that there had been little change in the patients' agoraphobia since six months after treatment. Some of the patients' self-ratings showed evidence of a slight improvement over this period. No evidence of symptom substitution was found.

Why whales are big but not bigger: Physiological drivers and ecological limits in the age of ocean giants

The largest animals are marine filter feeders, but the underlying mechanism of their large size remains unexplained. We measured feeding performance and prey quality to demonstrate how whale gigantism is driven by the interplay of prey abundance and harvesting mechanisms that increase prey capture rates and energy intake. The foraging efficiency of toothed whales that feed on single prey is constrained by the abundance of large prey, whereas filter-feeding baleen whales seasonally exploit vast swarms of small prey at high efficiencies. Given temporally and spatially aggregated prey, filter feeding provides an evolutionary pathway to extremes in body size that are not available to lineages that must feed on one prey at a time. Maximum size in filter feeders is likely constrained by prey availability across space and time.

Cardiac compression due to closure of the median sternotomy in open heart surgery

Following open heart surgery, approximation of the median sternotomy can compress the heart and produce cardiac tamponade. A proposed new technique to eliminate this compression by sternal traction is presented.

Change in pain and function while waiting for major joint arthroplasty

The objective of this study was to examine the change in pain and physical function that occurs while waiting for major arthroplasty. Data were collected prospectively from a cohort of 313 patients who were waiting > 1 month for total hip arthroplasty or total knee arthroplasty. The WOMAC and the SF-36 health status instruments were administered at the time the patient was placed on the waiting list and again just before surgery. Minimal amounts of change in pain and physical and psychosocial function occurred for hip and knee arthroplasty patients while they waited. Overall, waiting time did not appear to have a negative impact on the amount of pain and dysfunction experienced.

Temporal patterns in the acoustic signals of beaked whales at Cross Seamount

Seamounts may influence the distribution of marine mammals through a combination of increased ocean mixing, enhanced local productivity and greater prey availability. To study the effects of seamounts on the presence and acoustic behaviour of cetaceans, we deployed a high-frequency acoustic recording package on the summit of Cross Seamount during April through October 2005. The most frequently detected cetacean vocalizations were echolocation sounds similar to those produced by ziphiid and mesoplodont beaked whales together with buzz-type signals consistent with prey-capture attempts. Beaked whale signals occurred almost entirely at night throughout the six-month deployment. Measurements of prey presence with a Simrad EK-60 fisheries acoustics echo sounder indicate that Cross Seamount may enhance local productivity in near-surface waters. Concentrations of micronekton were aggregated over the seamount in near-surface waters at night, and dense concentrations of nekton were detected across the surface of the summit. Our results suggest that seamounts may provide enhanced foraging opportunities for beaked whales during the night through a combination of increased productivity, vertical migrations by micronekton and local retention of prey. Furthermore, the summit of the seamount may act as a barrier against which whales concentrate prey.

Type A behaviour and ischaemic heart disease in middle aged British men

The Bortner questionnaire, which measures aspects of type A (coronary prone) behaviour was completed by 5936 men aged 40-59 selected at random from one general practice in each of 19 British towns. The presence of ischaemic heart disease was determined at initial examination and the men were followed up for an average of 6.2 years for morbidity and mortality from myocardial infarction and for sudden cardiac death. Non-manual workers had significantly higher scores (more type A) than manual workers and the score decreased (less type A) with increasing age. After adjustment for social class and age men with higher scores had higher prevalences of ischaemic heart disease less marked for electrocardiographic evidence and more marked for response to a chest pain questionnaire (angina or possible myocardial infarction). A man's recall of a doctor's diagnosis of ischaemic heart disease, however, did not relate to his Bortner score. There was no significant relation between the Bortner score and the attack rate or incidence of major ischaemic heart disease events. In this study type A behaviour, as measured by the Bortner questionnaire, did not predict major ischaemic heart disease events in British middle aged men.

Marine mammal conservation: over the horizon

Marine mammals can play important ecological roles in aquatic ecosystems, and their presence can be key to community structure and function. Consequently, marine mammals are often considered indicators of ecosystem health and flagship species. Yet, historical population declines caused by exploitation, and additional current threats, such as climate change, fisheries bycatch, pollution and maritime development, continue to impact many marine mammal species, and at least 25% are classified as threatened (Critically Endangered, Endangered or Vulnerable) on the IUCN Red List. Conversely, some species have experienced population increases/recoveries in recent decades, reflecting management interventions, and are heralded as conservation successes. To continue these successes and reverse the downward trajectories of at-risk species, it is necessary to evaluate the threats faced by marine mammals and the conservation mechanisms available to address them. Additionally, there is a need to identify evidence-based priorities of both research and conservation needs across a range of settings and taxa. To that effect we: (1) outline the key threats to marine mammals and their impacts, identify the associated knowledge gaps and recommend actions needed; (2) discuss the merits and downfalls of established and emerging conservation mechanisms; (3) outline the application of research and monitoring techniques; and (4) highlight particular taxa/populations that are in urgent need of focus.

Effect of stress management on blood pressure in mild primary hypertension

OBJECTIVE

To establish whether stress management had a larger effect than a control treatment on resting blood pressure, ambulatory blood pressure, and left ventricular mass.

DESIGN

A 12 week baseline period of habituation to measurement of blood pressure was followed by randomisation to either stress management or mild exercise for six months and follow up six months later.

SETTING

General practice, district general hospital, and medical school.

PATIENTS

Of the 184 patients aged under 60 with mild primary hypertension who entered the baseline habituation period, 88 were excluded because they failed to meet the entry criteria or they withdrew from the study. The remaining 46 men and 50 women underwent treatment.

INTERVENTIONS

10 clinical sessions and daily practice at home of either stress management based on relaxation or non-aerobic stretching exercises. Mildly stressful 15 minute interviews before and after treatment.

MAIN OUTCOME MEASURES

Diastolic and systolic blood pressure in the clinic and during 12 hours of ambulatory recording, and left ventricular mass measured by echocardiography.

RESULTS

The patients' blood pressure fell during habituation (systolic pressure from 152 mmHg to 140 mmHg, diastolic pressure from 98 to 93 mm Hg), but neither resting nor ambulatory blood pressure was changed by the treatments. Left ventricular mass was also unchanged. Blood pressure rose during the stressful interview, but this rise was reduced by stress management (systolic pressure rose by 7.4 mmHg before treatment and by 3.7 mmHg after treatment).

CONCLUSION

Stress management of a type advocated for treating mild primary hypertension is ineffective in lowering blood pressure in patients who are well habituated to measuring blood pressure.

Relaxation and stress management in the treatment of essential hypertension

Thirty-two male and female hypertensives, 34 to 65 yr of age, systolic blood pressure (SBP) less than 200 mmHg and diastolic blood pressure (DBP) between 90 and 109 mmHg, were randomly allocated to receive either relaxation and stress management (experimental condition) or mild physical exercise (control condition). Half the participants were taking antihypertensive drugs, which were constant for six months prior to the study and controlled during the study. Outcome measures included various measures of blood pressure in the clinic and at home, cardiovascular responsiveness, moods and 24-hr urinary adrenaline and noradrenaline. The study schedule consisted of 3-months baseline, 10 weeks treatment and 3-months follow-up. Relaxation was superior to the control procedure in reducing blood pressure as assessed by nurses blind to the participants' treatment at post-treatment for DBP and at follow-up for DBP and SBP.