Experiences of verbal violence among people with intellectual disabilities in Israel

BACKGROUND

This study examines the extent of exposure to verbal violence experienced by people with intellectual disabilities and whether it differs based on their housing situation: living in the community, with family, or in a residential facility.

METHOD

One hundred and eighty-nine people with intellectual disabilities were interviewed about their experience with verbal violence.

RESULTS

Eighty-six percent reported experiencing verbal violence in their lifetime and approximately 77% experienced it the past week. Participants were most likely to be yelled at, and friends were the most common perpetrators. While there were few differences by setting, people living with their families were more likely to be laughed at and marginally more likely to experience rude comments.

CONCLUSIONS

Verbal violence is prevalent in the lives of people with intellectual disabilities in Israel. Interventions are necessary to assist people with intellectual disabilities to deal with such incidents, with possible additional supports needed for those living with family.

Predictors of worklife burnout among mental health certified peer specialists

Certified peer specialists (CPSs) are a growing workforce that uses their lived experience of a behavioral health disorders plus skills learned in formal training to deliver support services. Despite their important role in the mental health care system and research on their working conditions, experiences of burnout have not been widely studied among CPSs. This study uses survey data from CPSs who were currently employed in any type of job, providing peer support services or not. Using the Maslach Burnout Inventory (MBI) and Areas of Worklife Survey (AWS), along with other measures of personal and job characteristics, relationships of predictors variables to burnout measures were described in unadjusted and adjusted linear regression models. Scores on each of the averaged burnout measures differed significantly between those employed in peer services jobs and those in other job types, with those in peer services jobs reporting lower exhaustion, cynicism, and higher professional efficacy. Better workload and fairness were associated with significantly lower exhaustion, and better reward and community were both associated with significantly lower cynicism. Those employed in peer services jobs had fewer signs of burnout than those in other occupations, in keeping with prior research. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Treatment decision-making needs among emerging adults with early psychosis

AIM

Many emerging adults disengage from early intervention in psychosis (EIP) services prematurely. Service disengagement may be in part due to having unresolved treatment decision-making needs about use of mental health services. A basic understanding of the decision-making needs of this population is lacking. The purpose of this qualitative study was to identify the range of treatment decisions that emerging adults face during their initial engagement in an EIP program and elucidate barriers and facilitators to decision-making.

METHODS

Twenty emerging adults with early psychosis were administered semistructured interviews to capture treatment decision-making experiences during the first six months after enrolment in an EIP program. Interviews were audio-recorded and transcribed verbatim. Responses were independently coded by two authors using an integrated thematic analysis approach; differences in coding were discussed to consensus. Data analysis was facilitated using NVivo 12 Plus.

RESULTS

Emerging adults identified numerous decisions faced after EIP enrolment. Decisions pertaining to life and treatment goals and to starting and continuing psychiatric medication were commonly selected as the most difficult/complicated. Decision-making barriers included not having the right amount or type of information/knowledge, social factors (e.g., lacking social support, opposition/pressure), lacking internal resources (e.g., cognitive and communication skills, self-efficacy, motivation) and unappealing options. Obtaining information/knowledge, social supports (e.g., connection/trust, learning from others' experiences, encouragement), considering personal values, and time were decision-making facilitators.

CONCLUSIONS

This study informs development and optimization of interventions to support decision-making among emerging adults with early psychosis, which may promote service engagement.

A Systematic Review of Shared Decision-Making Interventions for Service Users With Serious Mental Illnesses: State of the Science and Future Directions

OBJECTIVE

Shared decision making (SDM) is a health communication model that may be particularly appealing to service users with serious mental illnesses, who often want to be involved in making decisions about their mental health care. The purpose of this systematic review was to describe and evaluate participant, intervention, methodological, and outcome characteristics of SDM intervention studies conducted within this population.

METHODS

Systematic searches of the literature through April 2020 were conducted and supplemented by hand searching of reference lists of identified studies. A total of 53 independent studies of SDM interventions that were conducted with service users with serious mental illnesses and that included a quantitative or qualitative measure of the intervention were included in the review. Data were independently extracted by at least two authors.

RESULTS

Most studies were conducted with middle-age, male, White individuals from Western countries. Interventions fell into the following categories: decision support tools only, multicomponent interventions involving decision support tools, multicomponent interventions not involving decision support tools, and shared care planning and preference elicitation interventions. Most studies were randomized controlled trials with sufficient sample sizes. Outcomes assessed were diverse, spanning decision-making constructs, clinical and functional, treatment engagement or adherence, and other constructs.

CONCLUSIONS

Findings suggest important future directions for research, including the need to evaluate the impact of SDM in special populations (e.g., young adults and racial-ethnic minority groups); to expand interventions to a broader array of decisions, users, and contexts; and to establish consensus measures to assess intervention effectiveness.

A Single-Year Cosmic Ray Event at 5410 BCE Registered in 14C of Tree Rings

The annual 14C data in tree rings is an outstanding proxy for uncovering extreme solar energetic particle (SEP) events in the past. Signatures of extreme SEP events have been reported in 774/775 CE, 992/993 CE, and ∼660 BCE. Here, we report another rapid increase of 14C concentration in tree rings from California, Switzerland, and Finland around 5410 BCE. These 14C data series show a significant increase of ∼6‰ in 5411-5410 BCE. The signature of 14C variation is very similar to the confirmed three SEP events and points to an extreme short-term flux of cosmic ray radiation into the atmosphere. The rapid 14C increase in 5411/5410 BCE rings occurred during a period of high solar activity and 60 years after a grand 14C excursion during 5481-5471 BCE. The similarity of our 14C data to previous events suggests that the origin of the 5410 BCE event is an extreme SEP event.

Evaluating the feasibility of a decision aid to promote shared decision making among young adults with first-episode psychosis: protocol for a pilot study

BACKGROUND

Young adults ages 18 to 25 with first episode psychosis (FEP) have an increased risk of discontinuation antipsychotic medications and psychiatric service disengagement that lead to symptom exacerbation and deterioration. We seek to (1) examine the feasibility, usability, and potential impact of a Shared Decision Making (SDM) Antipsychotic Medication Decision Aid (DA) on decision-making, adherence to the decision made, and service engagement among young adults with FEP and (2) understand the role of additional patient-level factors on SDM.

METHODS

A randomized controlled trial is being conducted in a coordinated specialty care community program for FEP in an urban setting. Eligible patients are randomly assigned to receive an intervention, the Antipsychotic Medication Decision Aid, or treatment as usual. Patients receive their assigned intervention before their medication appointment with the psychiatrist and complete four interviews: before the appointment (T0), after the appointment (T1), and at 3- and 6-month follow-ups (T2 and T3). The study staff and participating psychiatrists are not blinded to the intervention. The data are de-identified to maintain blinding during the analysis process. The primary aims are feasibility of intervention delivery and research procedures and preliminary impact of the intervention on SDM-related outcomes, medication adherence, and service engagement. As a secondary aim, we will explore the contribution of personality and motivation variables, clinical relationships, cognitive functioning, and mental-health-related stigma to SDM. If the sample size permits, we plan to conduct parametric tests such as independent-samples t tests at T1 to compare differences in SDM, adherence, and engagement scales. In the case of a small sample size, we will use non-parametric tests and descriptive statistics.

DISCUSSION

This protocol outlines the methodology for a feasibility pilot comparing the effect of a novel SDM Antipsychotic Medication encounter DA with treatment as usual on SDM, medication adherence, and service engagement in FEP care. SDM is endorsed as a framework for use in FEP and antipsychotic pharmacotherapy, but its impact on adherence and health outcomes is unclear. Understanding the potential contribution of an SDM Antipsychotic Medication DA compared with usual care in psychosis pharmacotherapy is critical. The study will help answer several key questions new to SDM research, including the contribution of personality and clinical relationships to SDM in mental health and psychosis in particular. The study will serve to gather feasibility data to inform future studies and scale-up.

TRIAL REGISTRATION

Ethics approval was obtained through Temple University's institutional review board (IRB) and the City of Philadelphia's Department of Public Health IRB. The study has been retrospectively registered with ClinicalTrials.gov as NCT04373590 on 29 April 2020. https://clinicaltrials.gov/ct2/show/NCT04373590?term=NCT04373590&draw=2&rank=1.

Welcoming places: Perspectives of individuals with mental illnesses

There are many factors that influence community participation of individuals with serious mental illnesses. Research often focuses on barriers to participation. This study, however, takes a different approach, by exploring features of community locations considered welcoming by individuals with serious mental illnesses. This is important because welcoming environments are more likely to promote community participation. Using a survey approach, 75 participants were asked to identify and describe locations where they felt welcomed as a person with a mental illness. Our findings suggest that there are a number of places within the general community individuals with serious mental illnesses perceive as welcoming. Participants described religious communities, restaurants/cafés shops, parks, libraries, and cultural centers. Welcoming places were often perceived as architecturally open, featuring natural light and plants. Places provided opportunities for individuals to engage in a number of activities (e.g., socializing, entertainment, improving health, among others); data suggest welcoming places facilitated reciprocal relationships. We link these findings to a number of key recovery principles and make recommendation for multilevel interventions. This study may facilitate conversations with mainstream community organizations about inclusion and strategies to create welcoming environments and with mental health providers to consider strategies to encourage participation in welcoming places. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Unmet Needs of People with Serious Mental Illness: Perspectives from Certified Peer Specialists

Examine the unmet needs of people with serious mental illness (SMI) from the perspective of certified peer specialists. 267 certified peer specialists from 38 states completed an online survey (female [73%], 50.9 [SD = 12] years, and non-Hispanic White [79.8%]). Many respondents reported a primary mental health diagnoses (n = 200), 22 respondents reported their diagnosis as schizophrenia spectrum disorder (11%), 46 respondents reported bipolar disorder (22.1%), 47 respondents reported major depressive disorder (22.6%), 29 respondents reported post-traumatic stress disorder (13.9%), 27 respondents reported alcohol/substance use disorder (13%), 2 respondents reported personality disorder (1%), and 12 reported "other" (5.8%). A mixed methods convergence analysis integrated quantitative with qualitative data. Social isolation (n = 160, 59.9%) and feeling lonely (n = 159, 59.6%) were the most highly endorsed unmet need, followed by the need to address chronic health conditions (n = 80, 30%), prevent mental health hospitalization (n = 71, 23.6%), and prevent drug use (n = 66, 24.7%). Four themes emerged: need to address basic necessities, loneliness and social isolation, hope, and addiction. Addressing loneliness and social isolation were identified as the primary unmet needs among people with SMI. Addressing co-morbid health conditions may simultaneously impact other unmet needs. Hope is an important intervention target. Initial insights from this study can be used to guide researchers' efforts to incorporate certified peer specialists perspectives in developing programs to meet the needs of people with SMI. Future research using participatory research methods can further examine these initial insights.

Smartphone Ownership, Use, and Willingness to Use Smartphones to Provide Peer-Delivered Services: Results from a National Online Survey

Assess certified peer specialists' smartphone ownership, use, and willingness to use smartphones to provide peer-delivered services. Certified peer specialist from 38 states completed an online survey. The final sample of 267 certified peer specialists included respondents from 38 states. The majority of certified peer specialists were female (73%; n = 195) and Caucasian (79.8%; n = 213), with an average age of 50.9 (SD = 12) years, range from 21 to 77 years. More than half of the certified peer specialists (82.1%; n = 184) were currently working in peer support positions. Of those who reported their mental health diagnoses, 11% reported their diagnosis as schizophrenia spectrum disorder, 22% of respondents reported bipolar disorder, and 23% reported persistent major depressive disorder. Nearly all respondents owned a smartphone (94.8%; n = 253), and everyone indicated that smartphones and tablets could enhance the services they deliver. Certified peer specialists reported substantial ownership and use of smartphones, comparable to existing national data. They are willing to deliver smartphone interventions for mental health and physical health self-management, suggesting that smartphones may be an increasingly useful tool for offering evidence-based care. Without Medicaid mandate, certified peer specialists are naturally trying to enhance peer delivered services with technology. Peer support could act as a mechanism to promote consumer engagement in a smartphone-based intervention. Certified peer specialist own and utilize smartphones, and the majority are willing to deliver technology-based and technology-enhanced interventions using these devices to address medical and psychiatric self-management.

A menu with prices: Annual per person costs of programs addressing community integration

Information on costs of programs addressing community integration for persons with serious mental illness in the United States, essential for program planning and evaluation, is largely lacking. To address this knowledge gap, community integration programs identified through directories and snowball sampling were sent an online survey addressing program costs and organizational attributes. 64 Responses were received for which annual per person costs (APPC) could be computed. Programs were categorized by type of services provided. Program types differed in median APPCs, though median APPCs identified were consistent with the ranges identified in the limited literature available. Multiple regression was used to identify organizational variables underlying APPCs such as psychosocial rehabilitation program type, provision of EBPs, number of volunteers, and percentage of budget spent on direct care staff, though effects sizes were moderate at best. This study adds tentative prices to the menu of community integration programs, and the implications of these findings for choosing, designing and evaluating programs addressing community integration are discussed.

National Survey on Implementation of Peer Specialists in the VA: Implications for Training and Facilitation

OBJECTIVES

Peer support is fundamental to the promotion of recovery as indicated in the President's New Freedom Commission Report. Five years into the Department of Veterans Affairs' (VA) initiative to hire Peer Specialists (PSs)-individuals with serious mental illnesses assigned to clinical teams to support others with serious mental illnesses-this study explored challenges, facilitators, and progress of PS implementation from a stakeholder group involved in their management.

METHODS

Ninety-two VA Local Recovery Coordinators (LRCs) from across the nationwide VA mental health system were surveyed about their perceptions about PS hiring, status of implementation, impact, barriers and facilitators to successful employment of PSs, and willingness to support implementation.

RESULTS

The data suggest that PS implementation is going well overall, but challenges remain such as hiring delays, lack of understanding about the PS role, and lack of funding.

CONCLUSIONS AND IMPLICATIONS

Implementation challenges can undermine the employment of PSs. The VA and other organizations using PSs could improve implementation by monitoring the challenges and proactively facilitating the process on an ongoing basis.

Converting partial hospitals to community integrated recovery centers

This paper describes the conversion of partial hospitals into recovery-oriented programs as part of system transformation. Steps included: participatory planning with stakeholders; strength based assessment of resources and needs; technical assistance; and changing funding strategies. Over a period of 8 years, use of partial hospitals decreased as persons with serious mental illnesses were transitioned to community integrated recovery centers. Preliminary outcomes suggest that these programs are more effective in engaging people in the community activities of their choice, confirming previous findings that showed that partial hospitals can be converted to recovery-oriented programs that focus more directly on promoting community inclusion.

Examining the factor structure of the recovery assessment scale

This article follows up on earlier research examining the factor structure of a measure of recovery from serious mental illness. Exactly 1,824 persons with serious mental illness who were participating in the baseline interview for a multistate study on consumer-operated services completed the Recovery Assessment Scale (RAS) plus measures representing hope, meaning of life, quality of life, symptoms, and empowerment. Results of exploratory and subsequent confirmatory factor analyses of the RAS for random halves of the sample yielded five factors: personal confidence and hope, willingness to ask for help, goal and success orientation, reliance on others, and no domination by symptoms. Subsequent regression analyses showed that these five factors were uniquely related to the additional constructs assessed in the study. We compared these findings with those of other studies to summarize the factor structure that currently emerges on recovery.

Research to improve the quality of care for depression: alternatives to the simple randomized clinical trial

Recognition of gaps between evidence gained from mental health research and clinical practice in the community together with changes in treatment patterns and patient/provider preferences for care have led to interest in enhancements in the designs and analyses of clinical and community trials of mental health interventions. Gaps between clinical trials and community care include differences in populations and treatment strategies. To bridge these gaps, we propose enhancing the simple randomized trial with several different designs with the immediate aims of improving patient recruitment and adherence in psychiatric intervention studies thus bringing study designs more in line with clinical practice. The goals are to estimate treatment efficacy and effectiveness so that both internal and external validity are optimized. In this discussion, we address design and analytic issues with respect to a number of enhancements of the randomized trial design, including partial patient-provider preference designs, randomized encouragement and consent designs, fixed adaptive design, and random between- and within-patient adaptive designs. Each has advantages and disadvantages depending on the effect under investigation. Some of these enhancements, such as the fixed adaptive design, have begun to be implemented in effectiveness trials in mental health services research, but all are worthy of more attention.

A two-faceted work participation approach to employment and career development as applied to persons with a psychiatric disability

The work histories of persons with severe and persistent psychiatric disabilities are generally characterized by sporadic employment interspersed with long periods of unemployment during which they are supported by and often become dependent upon such forms of public aid as SSI or SSDI. This paper first describes a multifaceted work participation approach to employment and career building. It then explores the implications that this approach has for establishing future directions for research and interventions aimed at improving the quantity and quality of the participation in the work life domain of persons with a psychiatric disability.

Debris from failed ceramic-on-ceramic and ceramic-on-polyethylene hip prostheses

To compare the properties of wear debris between ceramic-on-ceramic and ceramic-on-polyethylene total hip prostheses, particles were isolated and characterized from tissue biopsies obtained at revision arthroplasty or autopsy from two similar uncemented modular hip systems. Group A hips (11 patients; mean, 31 months in vivo) had titanium shells with alumina inserts, alumina femoral heads, and titanium alloy stems. Group B hips (seven patients; mean, 42 months) were the same as Group A but with polyethylene acetabular inserts. Particles were characterized using an electrical resistance particle analyzer, scanning electron microscope, and energy dispersive xray spectroscope. Most of the particles in Group A were ceramic, whereas most of the particles in Group B were polyethylene. Metal particles from the femoral stem and the acetabular shell also were present. If one Group A hip with impingement is excluded, the rate of particle production is significantly lower in the ceramic-on-ceramic group than in the ceramic-on-polyethylene group. With the number of samples available, no significant difference in average size could be detected among the different types of particles or among the groups.

Moderate to severe hallux valgus deformity: correction with proximal crescentic osteotomy and distal soft-tissue release

Between 1991 and 1995, 96 patients (114 feet) were treated with a proximal crescentic metatarsal osteotomy and distal soft-tissue procedure for moderate to severe hallux valgus deformity [intermetatarsal (IM) angle > 15 degrees, or hallux valgus (HV) angle > 30 degrees]. At an average follow-up of 26 months, 8 men and 62 women (86 feet) with a mean age of 53.2 years were retrospectively reviewed. The HV angle averaged 41.1 degrees preoperatively and 14.6 degrees postoperatively. The respective values for the IM angle were 17.8 degrees and 7.8 degrees. Neither the average metatarsal shortening of 3 mm nor the dorsal angulation at the osteotomy site seen in 9% of cases evidenced any clinical significance at follow-up. Patient satisfaction was excellent or good in 91%, and the mean Mayo Clinic Forefoot Score (total 75 points) improved from 37.2 to 61.1 points. Complications included 8 cases of hallux varus and 5 cases of hardware failure. Based on this first study exclusively focusing on moderate to severe hallux valgus deformity, we conclude that proximal first metatarsal osteotomy in combination with a lateral soft-tissue procedure is effective in correcting moderate to severe symptomatic hallux valgus deformity with metatarsus primus varus (IM angle > 15 degrees or HV angle > 30 degrees).

Comparison of migration in modular sockets with ceramic and polyethylene inlays

This study compared migration in 73 cementless total hip arthroplasties (THAs) with either alumina ceramic (n = 23) or polyethylene (n = 50) inlays; prosthesis sockets and stems were identical except for the inlays. After 7 years of follow-up, 5 sockets (4 with ceramic and 1 with polyethylene inlays) had been revised an average of 63.3 months (range: 49-81 months) after implantation, and survival analysis showed a significantly higher revision rate for sockets with ceramic inlays (89 +/- 6%) versus polyethylene inlays (98.2 +/- 1.7%) (P = .032). Migration analysis of the first three postoperative years revealed significantly higher vertical migration in sockets with ceramic inlays (P = .047), in patients aged <60 years (P = .02), and in osteoporotic type C bone (A versus C, P = .0071 and B versus C, P = .0004).

Alumina ceramic bearings for hip endoprostheses: the Austrian experiences

The current authors review clinical and retrieval experiences with hemispheric monolithic alumina ceramic sockets (Group 1), implanted between 1976 and 1979, and similar modular titanium sockets with alumina ceramic inlays (Group 2), implanted between 1990 and 1995. Both cementless sockets articulated with alumina ceramic femoral ball heads for total hip joint replacements. Clinical followup of patients with hemispheric monolithic alumina ceramic sockets (Group 1, 138 sockets) resulted in a total failure rate of 19.6% after 5 to 20 years. Radiologic analysis of eight stable sockets showed migration of 0.2 mm to 2.89 mm, but in four sockets at risk for late aseptic failure after an average followup of 12.5 years as much as 13.4 mm of migration was seen. Histologic evaluation revealed pseudosynovial membranes as thick as 1 mm with fine birefringent wear particles within mononuclear macrophages around two stable retrieved sockets. The membranes around four loose sockets were 6 to 10 mm thick and also heavily loaded with larger alumina wear particles. After 7 years followup clinical analysis of patients with modular titanium sockets with alumina ceramic inlays (Group 2, 30 sockets) resulted in four revisions, compared with one revision of 50 identical sockets (control group) with polyethylene instead of alumina ceramic inlays. Wear particle analyses in scanning electron microscopy showed significantly more particles (x 10(9) +/- standard deviation/g dry tissue) from the control group (4.26+/-6.38), compared with alumina ceramic bearings of Group 1 (0.70+/-0.79), and of Group 2 (1.62+/-2.13). The alumina particle sizes ranged between 0.13 and 78.38 microm. The mean annual linear wear of 38.8 microm was calculated for the bearings in Group 1, and of 26.94 microm for bearings in Group 2. These results support the good tribologic and biologic performance of alumina ceramic bearings for total hip arthroplasty.

The chevron osteotomy for correction of hallux valgus. Comparison of findings after two and five years of follow-up

BACKGROUND

The chevron osteotomy, an accepted method for the correction of mild and moderate hallux valgus, is generally advocated for patients younger than the age of fifty years. The purposes of this prospective study were to compare the short-term (two-year) and intermediate-term (five-year) results of this operation with respect to patient satisfaction, flexion and extension of the metatarsophalangeal joint, maintenance of correction, and development of arthrosis and to determine whether the effectiveness of the procedure was limited by age.

METHODS

Between April 1991 and September 1992, the chevron osteotomy was performed for the treatment of mild-to-moderate hallux valgus deformity in sixty-six consecutive feet. Forty-three patients (fifty-seven feet) were available for follow-up at both two and five years postoperatively. The two-year and five-year clinical assessments were based on the American Orthopaedic Foot and Ankle Society's hallux-metatarsophalangeal-interphalangeal scale.

RESULTS

Between the two-year and five-year follow-up evaluations, there was only a minimal change in overall patient satisfaction, and the average score on the hallux-metatarsophalangeal-interphalangeal scale was unchanged. The passive range of motion of the first metatarsophalangeal joint decreased between the preoperative assessment and the two-year follow-up evaluation and was unchanged at the five-year follow-up evaluation. Radiographic evaluation showed no changes in the hallux valgus or intermetatarsal angle between the two-year and five-year evaluations, although the number of feet with arthrosis of the metatarsophalangeal joint increased slightly, from eight to eleven. Patients aged fifty years or older did as well as younger patients.

CONCLUSIONS

At these two follow-up periods, the chevron osteotomy was found to be a reliable procedure for the correction of mild and moderate hallux valgus deformity, and outcome did not differ on the basis of age.

Wear debris from two different alumina-on-alumina total hip arthroplasties

We compared wear particles from two different designs of total hip arthroplasty with polycrystalline alumina-ceramic bearings of different production periods (group 1, before ISO 6474: group 2, according to ISO 6474). The neocapsules and interfacial connective tissue membranes were retrieved after mean implantation times of 131 months and 38 months, respectively. Specimen blocks were freed from embedding media, either methylmethacrylate or paraffin and digested in concentrated nitric acid. Particles were then counted and their sizes and composition determined by SEM and energy-dispersive x-ray analysis (EDXA). The mean numbers and sizes of most alumina wear particles did not differ for both production periods, but the larger sizes of particle in group 1 point to more severe surface destruction. The increased metal wear in group 2 was apparently due to alumina-induced abrasion of the stems. In this study the concentrations of particles in the periprosthetic tissues were 2 to 22 times lower than those observed previously with polyethylene and alumina/polyethylene wear couples.

Wear debris from two different alumina-on-alumina total hip arthroplasties

We compared wear particles from two different designs of total hip arthroplasty with polycrystalline alumina-ceramic bearings of different production periods (group 1, before ISO 6474: group 2, according to ISO 6474). The neocapsules and interfacial connective tissue membranes were retrieved after mean implantation times of 131 months and 38 months, respectively. Specimen blocks were freed from embedding media, either methylmethacrylate or paraffin and digested in concentrated nitric acid. Particles were then counted and their sizes and composition determined by SEM and energy-dispersive x-ray analysis (EDXA).

The mean numbers and sizes of most alumina wear particles did not differ for both production periods, but the larger sizes of particle in group 1 point to more severe surface destruction. The increased metal wear in group 2 was apparently due to alumina-induced abrasion of the stems. In this study the concentrations of particles in the periprosthetic tissues were 2 to 22 times lower than those observed previously with polyethylene and alumina/polyethylene wear couples.

Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care

BACKGROUND

Primary care treatment of depression needs improvement.

OBJECTIVE

To evaluate the efficacy of 2 augmentations to antidepressant drug treatment.

DESIGN

Randomized trial comparing usual care, telehealth care, and telehealth care plus peer support; assessments were conducted at baseline, 6 weeks, and 6 months.

SETTING

Two managed care adult primary care clinics.

PARTICIPANTS

A total of 302 patients starting antidepressant drug therapy.

INTERVENTIONS

For telehealth care: emotional support and focused behavioral interventions in ten 6-minute calls during 4 months by primary care nurses; and for peer support: telephone and in-person supportive contacts by trained health plan members recovered from depression.

MAIN OUTCOME MEASURES

For depression: the Hamilton Depression Rating Scale and the Beck Depression Inventory; and for mental and physical functioning: the SF-12 Mental and Physical Composite Scales and treatment satisfaction.

RESULTS

Nurse-based telehealth patients with or without peer support more often experienced 50% improvement on the Hamilton Depression Rating Scale at 6 weeks (50% vs 37%; P =.01) and 6 months (57% vs 38%; P =.003) and on the Beck Depression Inventory at 6 months (48% vs 37%; P =. 05) and greater quantitative reduction in symptom scores on the Hamilton scale at 6 months (10.38 vs 8.12; P =.006). Telehealth care improved mental functioning at 6 weeks (47.07 vs 42.64; P =.004) and treatment satisfaction at 6 weeks (4.41 vs 4.17; P =.004) and 6 months (4.20 vs 3.94; P =.001). Adding peer support to telehealth care did not improve the primary outcomes.

CONCLUSION

Nurse telehealth care improves clinical outcomes of antidepressant drug treatment and patient satisfaction and fits well within busy primary care settings.

Stable bony integration with and without short-term indomethacin prophylaxis. A 5-year follow-up

We included in a prospective study of a standardized indomethacin protocol 134 consecutive patients undergoing primary cementless endoprosthetic hip replacement between January and June 1990. Periarticular heterotopic ossification (HO) was graded according to the Arcq classification (grades 0 to III). At final follow-up, all patients were analyzed clinically and radiographically for HO and aseptic loosening. A similar group of 44 patients (mean age of 64 years, range 38-82 years) undergoing total hip replacement (THR) with the same prosthesis and technique in 1987 did not receive HO prophylaxis and served as a control group. The average age of the 134 prophylaxis patients was 66.5 years (range 32-85 years), and the average follow-up was 65 months (range 60-71 months). Thirty patients (25%) were lost to final follow-up (19 died, 10 unknown, 1 amputation). In the study group, 77% had HO grade 0, while none had HO grade III, compared with 18% HO grade 0 and 16% HO grade III in the control group. These differences were statistically significant (P = < 0.001). At a minimum of 60 months follow-up, clinical and radiographic evaluation revealed no aseptic loosening in the study group: 4 cases of prosthesis subsidence during the first year did not progress. In the control group, there was a higher incidence of radiolucency around the femoral component, and one patient met all criteria for radiographic evidence of aseptic loosening. Statistical analysis revealed no significant difference between the two groups (P = 0.104). Based on our clinical and radiological results, indomethacin does not inhibit stable bony integration of the femoral component.

Basal closing wedge osteotomy for correction of hallux valgus and metatarsus primus varus: 10- to 22-year follow-up

Between 1974 and 1985, 59 patients (83 feet) underwent basal closing wedge osteotomy in combination with a bunionectomy and a lateral soft tissue release for correction of hallux valgus and metatarsus primus varus at this institution. Of the original 59 patients, 42 patients (60 feet) with at least 10 years of follow-up (average, 194 months; range, 144-266 months) were available for this study. Results were analyzed by review of the medical records and plain radiographs, a standardized clinical questionnaire, and physical examination. Of the 60 feet, patients rated outcomes as excellent or good in 51 feet (85%) and rated cosmesis as excellent or good in 44 feet (73%). Radiographically at final follow-up, hallux valgus and intermetatarsal angles averaged 19.9 degrees (range, 0-40 degrees) and 6.7 degrees (range, 0-18 degrees), respectively. The sesamoid position was corrected from an average preoperative grade of 2.6 to a grade of 0.9 at final follow-up. The average shortening of the first metatarsal was 5 mm. The disadvantages of the closing wedge osteotomy are that it is technically demanding and it entails the risk of shortening, dorsal malalignment, and metatarsalgia. In the current study, long-term complications included hallux varus deformity (16 feet), dorsal malalignment (15 feet), and metatarsalgia (14 feet). Despite good correction of the intermetatarsal angle and sesamoid position, the clinical results and the incidence of complications after basal closing wedge osteotomy were not as favorable as those reported for other procedures in the literature. Therefore, alternative procedures, such as the basal crescentic osteotomy or the basal chevron osteotomy, should be used.

In vivo femoral intramedullary pressure during uncemented hip arthroplasty

There is evidence in several animal and human studies that high intramedullary pressure in the femur is of causal significance for bone marrow release into the circulation, causing pulmonary fatty marrow embolization. A previous clinical study provided evidence that in uncemented hip arthroplasty, high intramedullary pressure and subsequent fat embolism with cardiorespiratory deterioration can occur. In this prospective clinical trial, the effect of five surgical techniques on the femoral intramedullary pressure was recorded intraoperatively in 36 patients during uncemented press fit hip arthroplasty. In Group A, the conventional surgical technique (slide hammer and femoral rasps) showed intramedullary hypertension during opening of the femoral canal, femur preparation, and prosthesis insertion. In Group B, a mechanical high frequency vibration rasp was used, instead of the slide hammer, and provided reduction of the intramedullary pressure peaks during opening of the femoral canal but could not prevent intramedullary hypertension during rasping and prosthesis insertion. In Group C, a modified surgical technique to prevent high intramedullary pressure reduced pressure peaks during opening of the femoral canal and resulted in a significant reduction of intramedullary pressure during femur preparation and prosthesis insertion compared with the conventional surgical technique used with Group A. In Group D the results of the modified surgical technique could be improved additionally by using the high frequency vibration rasp, instead of the slide hammer. In Group E conventional surgical technique in combination with a distal venting hole has not proven to be efficient in uncemented hip arthroplasty. Based on the results of this in vivo study, the proposed modified surgical technique in cementless hip arthroplasty can be recommended to avoid high intramedullary pressure peaks, which should minimize the risk of significant bone marrow release into the circulation and the risk for cardiorespiratory deterioration caused by fat embolism.

General short-term indomethacin prophylaxis to prevent heterotopic ossification in total hip arthroplasty

This prospective study evaluated heterotopic ossification prophylaxis with indomethacin for 14 days in 201 consecutive patients undergoing total hip arthroplasty. Ranitidine was administered concurrently to alleviate gastrointestinal side effects. None of the patients with mild gastrointestinal side effects (12%) had to suspend the prophylaxis, and no major postoperative bleeding or gastrointestinal ulcers were observed. After 12 months of follow-up, 67% of patients had no evidence of heterotopic ossification, 32% percent had grades I and 1% had grade III without clinical significance, and 0% had grade IV ossification according to Brooker's classification. These results indicate that short-term indomethacin prophylaxis is an effective, inexpensive, and easily administrated alternative to single-dose radiotherapy for nearly all patients undergoing THA.

[Long-term results of basal wedge osteotomy in metatarsus primus varus in the young patient]

INTRODUCTION

Aim of this retrospective study was to analyse the long term results after basal closing wedge osteotomy for correction of metatarsus primus varus and hallux valgus in the younger patient.

PATIENT AND METHODS

49 patients (70 feet) were operated according to a basal closing wedge osteotomy from 1974 to 1985 at our institution. Age was under 40 years in all patients at the time of surgery. 34 patients (50 feet) were evaluated in respect to their clinical and 26 patients (37 feet) to their radiological outcome. The average age was 26 years (14-39 years). The follow-up was 12 to 22 years (Median: 18 years). Analysis was performed using the patient's record, weight-bearing X-rays, a standardized questionnaire and clinical investigation.

RESULTS

82% of the patients had very good and good subjective results. Cosmetics was rated very good and good in 78%, 88% of the patients were painfree. Radiological analysis at follow-up: Hallux valgus-angle 19,3 degrees, intermetatarsal I/II-angle 6 degrees, shortening of first metatarsale 5 mm, at average; dorsal elevation of first metatarsale 38%, degenerative arthritis of the metatarsocuneiforme joint 19%, congruency of first metatarsophalangeal joint 54%,sesamoid subluxation: 46% grade 0, 30% grade I, 14% grade II and 10% grade III. In 14 feet (28%) metatarsalgia was found.

DISCUSSION

The basal closing wedge osteotomy is rather a technically demanding procedure conjuncted with a higher risk of failure. Satisfactory long term results can be obtained by an ideal operating technique. As undesirable side effects shortening of the first ray and dorsal malangulation of the first metatarsale may occur consecutively leading to metatarsalgia. Lower risk procedures like the crescentic osteotomy according to Mann or chevron osteotomy should be preferred.

Modified Austin procedure for correction of hallux valgus

The Austin osteotomy is a widely accepted method for correction of mild and moderate hallux valgus. In view of publications by Kitaoka et al. in 1991 and by Mann and colleagues, a more radical lateral soft tissue procedure was added to the originally described procedure. From September 1992 to January 1994, 85 patients underwent an Austin osteotomy combined with a lateral soft tissue procedure to correct their hallux valgus deformities. Seventy-nine patients (94 feet) were available for follow-up. The average patient age at the time of the operation was 47.1 years, and the average follow-up was 16.2 months. The average preoperative intermetatarsal angle was 13.9 degrees, and the average hallux valgus angle was 29.7 degrees. After surgery, the feet were corrected to an average intermetatarsal angle of 5.8 degrees and an average hallux valgus angle of 11.9 degrees. Sesamoid position was corrected from 2.1 before surgery to 0.5 after surgery. The results were also graded according to the Hallux Metatarsophalangeal Interphalangeal Score, and the functional and cosmetic outcomes were graded by the patient. Dissection of the plantar transverse ligament and release of the lateral capsule repositioned the tibial sesamoid and restored the biomechanics around the first metatarsophalangeal joint. There was no increased incidence of avascular necrosis of the first metatarsal head compared with the original technique.

[Correction of high-grade sesamoid bone dislocation in hallux valgus using Austin's osteotomy with and without lateral soft tissue release]

INTRODUCTION

Aim of this study was to analyze if, using the Austin technique for correction of hallux valgus deformity, the additional soft tissue procedure is capable to achieve better correction of the sesamoid subluxation, the hallux valgus angle and the intermetatarsal angle.

PATIENTS AND METHODS

19 patients with 20 feet operated according to the original Austin technique and 26 patients with 28 feet operated according to a modified technique with lateral soft tissue release both with a preoperative sesamoid subluxation grade 3 were compared with the help of a standardized questionnaire in respect to clinical and radiological results.

RESULTS

Analyzing the clinical outcome of the two procedures, there was no statistical difference. Comparison of the radiological results revealed a significantly better correction of the sesamoid position and a better correction of hallux valgus and intermetatarsal angle by using the additional soft tissue procedure.

DISCUSSION

The lateral soft tissue procedure with release of the adductor hallucis, dissection of the deep transverse plantar ligament and mobilisation of the sesamoids is capable of a significantly better correction of the sesamoid position. Only a combination of osseus and soft tissue correction is capable to correct the pathomechanism and to guarantee long lasting results.

Helal metatarsal osteotomy for the treatment of metatarsalgia: a critical analysis of results

We reviewed the results of treatment of 114 feet in 96 patients with pressure metatarsalgia treated with a metatarsal osteotomy performed according to the technique of Helal. Clinical examination was performed according to a standardized evaluation questionnaire using the American Orthopaedic Foot and Ankle Society Lesser Metatarsophalangeal-Interphalangeal Scale. The results were correlated with number of metatarsal osteotomies, the length of the follow up, the age of the patient, and type of additional procedures performed. Sixty-one percent of the patients rated the operation as excellent or good. Patient age and number of osteotomies did not influence the results; however, the length of time following surgery and associated Keller-Brandes resection arthroplasty influenced the outcome negatively. There was a high incidence of increased transfer of weight to adjacent metatarsals. We concluded that the Helal type metatarsal osteotomy is unlikely to predictably achieve symptom relief over a long period.

[Prognosis of hip endoprostheses after disorders of wound healing]

41 draining sinuses after THR were treated by debridement without exchanging the implants. Positive bacterial cultures were obtained in 23 patients-the ilio tibial tract was found open in 19 cases (82%). The bacterial cultures were negative in 18 patients-the ilio tibial tract was found open in 7 cases (38%). Revisions took place 21 days (9-43) after primary implantation. At the time of the follow up (0 72 months postoperatively) 7 patients had been revised (8-97) because of recurrence of infection. The results of debridements of contaminated sinuses depend on the ilio tibial tract. Revisions were successful in three out of four paces with an intact, and only in eight out of nineteen cases with an open ilio tibial tract. Besides proper bacterial investigation preoperative sinograms give useful information about the prognosis of revision. In cases with positive bacterial cultures debridements should be done very early to eradicate infection without removing the implants.

Clinical and radiological results after Austin bunionectomy for treatment of hallux valgus

The results of the Austin osteotomies for hallux valgus deformity performed at the Orthopedic Hospital Gersthof were reviewed at least 1 year after surgery. Of the 53 consecutive patients (66 operations) with an average follow-up of 24.3 months, 49 patients (62 feet) were interviewed. Of the reviewed patients 86.6% achieved good or excellent clinical results. The complication rate was 8%, including hallux varus n (3), superficial n (1) and deep n (1) wound infections, hypoaesthesia n (2), and reflex sympathetic dystrophy n (1). There was one case of avascular necrosis of the first metatarsal head and none of non-union. The Austin osteotomy is a safe and effective treatment of mild and moderate hallux valgus deformity.

[Monitoring of bone marrow spilling and cardiopulmonary changes in fat embolism syndrome]

After long bone fractures, as well as hip or knee total arthroplasty, the increase in intramedullary pressure induces bone marrow release into the circulation in more than 90% of patients. Three to four percent of the patients reveal fat embolism syndrome with pulmonary and cerebral involvement and a petechial rash. In about 20% of these patients a fulminant and fatal course is possible. Although fat embolism syndrome was described more than a century ago, there is still no sufficient therapeutic strategy. Because of these facts we try to prevent fat embolism syndrome and monitor patients at risk perioperatively. We have evaluated different diagnostic methods and monitoring facilities and recommend pulse oximetry, capnography, ECG, blood pressure controls and, if indicated, blood gas analyses for perioperative monitoring. Patients at risk and patients who are suffering from fat embolism syndrome require more intensive monitoring, such as transesophageal echocardiography and a pulmonary artery catheter to obtain more detailed information about the hemodynamic and oximetric variables. Furthermore, these patients must be admitted to an intensive care unit.

[Modified surgical technique for reduction of bone marrow spilling in cement-free hip endoprosthesis]

Since 1970 the fat embolism syndrome (FES) has been recognised as a severe complication of cemented total hip arthroplasty (THA). Initially and still today the toxicity of bone cement has been though to be responsible for the cardiorespiratory problems. Meanwhile several reports have confirmed the causal relationship between intramedullary pressure (IMP), bone-marrow release into the circulation and subsequent cardiorespiratory deterioration during cemented THA. In recent publications it has been reported that bone-marrow release due to increased IMP also occurs during cementless THA. The clinical implication of these observations is controversial. For this reason in the first part of this paper two autopsy-proven FES deaths and five further clinically manifest FES cases are presented. In the second part of the study, IMP courses during four different surgical techniques (2 conventional, 2 modified) are compared. The aim of the modified surgical technique developed in our department was to minimize IMP peaks and bone-marrow release during cementless THA. Both modified techniques showed significantly lower IMPs during opening of the medullary canal, preparation with rasps, and implantation of the prosthesis than the conventional techniques. The observed FES cases for the first time strongly confirm the clinical relevance of the FES, also during cementless THA. On the basis of the data presented we recommend the modified surgical technique to reduce bone-marrow release during cementless THA.

[Modified surgical technique for the reduction of bone marrow spilling in knee endoprosthesis]

In the literature 20 cases of fat embolism syndrome (FES) after total knee replacement (TKR) are reported; 16 cases had cemented hinged TKR and 4 resurfacing TKR. Initially, it was believed that the bone cement was responsible for the FES. Since then, however, Fahmy et al. have published extraordinary data, demonstrating the causal relationship between increased intramedullary pressure (IMP) during the insertion of the intramedullary rod (IR) and cardiorespiratory deterioration. The industry responded by developing a fluted IR, disregarding the overdrilling in the distal femur required by Fahmy. In the first part of this paper clinically manifest FES cases after resurfacing TKR are reported. In the second part of the study the conventional surgical technique is compared with a modified technique, which focuses on a reduction of bone-marrow release into the circulation. In the conventional and the modified group, IRs with and without flutes were compared. It was shown that only the opening of the intramedullary canal and insertion of the IR generated relevant IMP peaks during implantation of resurfacing TKR. When compared with the conventional surgical technique, the modified technique revealed significantly lower IMPs, and in neither group was a difference demonstrated between the IR with or without flutes. In 4 patients (2 conventional, 2 modified) transesophageal echocardiography (TEE) was performed for detection of bone-marrow release into the circulation. In the two patients operated on conventionally, TEE showed a markedly higher bone-marrow release than in the patients with modified operations. In conclusion, we recommend the presented modified surgical technique in order to reduce bone-marrow release into the circulation.

[Therapeutic approach to the management of fat embolism syndrome]

So far, no clinical or experimental study has demonstrated that any drug has a beneficial effect (heparin, cortisone, dextran, etc.) on the course of fat embolism syndrome (FES). Thus, prevention, early diagnosis, and adequate symptomatic treatment are of paramount importance. Besides surgical measures, such as reduction of intraosseous pressure and bone-marrow release during hip or knee replacement, proper treatment of shock in traumatized patients, recognition of risk factors and maintainance of intraoperative cardiorespiratory stability are cornerstones in the prevention of fat embolism syndrome. It is well documented that bone-marrow release into the circulation and pulmonary embolism occurs during any hip or knee arthroplasty. As a result of improvements in anesthesia management, the clinical appearance of FES has moved into the postoperative period. This calls for mandatory cardiorespiratory monitoring up to 24 h postoperatively. When facing a clinically manifest fat embolism syndrome, monitoring and symptomatic treatment must be adapted to the patient's needs in order to ensure adequate oxygenation and acceptable circulatory conditions to protect organ function.

[Pathophysiology of fat embolisms in orthopedics and traumatology]

It is well known that fat embolisms can occur after long bone fractures, and this has been feared for more than 100 years. Since 1970 fat embolisms have also been recognized in endoprosthetic surgery. The clinical manifestation was described as the fat embolism syndrome (FES) by Gurd in 1974. Based on reports in the literature and our own data, a concise pathophysiological model of the FES is presented in this paper. The increase in intramedullary pressure (IMP) in the long bones is the most decisive pathogenic factor for the development of an FES. Any long bone fracture, stabilization of fractures, or implantation of knee or hip endoprostheses can generate IMP peaks leading to bone marrow release into the circulation. Bone marrow itself is a tremendous stimulus for activation of the clotting system. As a result, hypercoagulation and venous stasis in the draining veins generate mixed macroemboli from the initial bone-marrow microemboli. Bone-marrow embolization of the lung in phase I leads to mechanical obstruction of pulmonary arteries. In phase II, release of local mediators, triggered by a systemic inflammatory response (SIR) of the lungs, causes damage to the pulmonary membranes. Disturbed gas exchange and respiratory insufficiency with possible cardiac and cerebral decompensation are the result. In most cases an FES may not be detected clinically, and any mild cardiorespiratory changes are treated easily with oxygen insufflation and usually disappear within 48 h. Of paramount importance for clinical manifestation of an FES are the quantity and duration of bone-marrow release and co-factors (cardiorespiratory compliance and perioperative stability of the patient). Patients with preexisting cardiorespiratory disease in combination with massive intraoperative bone-marrow release may even face a deadly FES event. Increased IMP causes local obstruction of cortical vessels with bone marrow. In combination with the damaged endosteal blood supply, avascular necrosis of the cortical bone occurs. During endoprosthetic procedures, mechanical-and mediator-triggered damage of the intima of big veins, in combination with venous stasis and hypercoagulation may be responsible for the high incidence of proximal thrombosis of femoral veins. As a delayed result of the disseminated intravascular coagulopathy, petechial bleeding in the trunk and subconjunctiva can be seen. A better understanding and recognition of the FES's pathophysiology may help to use prophylactic, diagnostic and therapeutical measures more effectively.

Ten-year results of cemented Weller-type total hip arthroplasties. Analysis using different definitions of failure

The first 100 consecutive cemented Weller-type total hip arthroplasties carried out between 1976 and 1977 were reexamined. Clinical analysis of 43 implants with more than 10 years follow-up showed that results were excellent in 21 patients (49%), good in 13 (30%), fair in 7 (16%) and poor in 2 (5%). Radiographic analysis revealed 33 (87%) stable femoral and 31 (81%) stable acetabular components. Statistical survivorship analysis of all 100 implants produced a probability of reoperation of 6.2%, a probability of radiographic implant loosening of 28.2% and a probability of radiographic loosening with clinical symptoms of 7.6%. The definition of failure should be "radiographic loosening of the prosthesis with clinical symptoms" because this evaluation seems to have the best clinical relevance. Concerning the fact that the cement fixation was not performed to today's standard, the results after more than 10 years with this total hip system (Weller long stem) are sufficient.

Long-term results of uncemented alumina acetabular implants

We report the clinical and tribological performance of 67 ceramic acetabular prostheses implanted between 1976 and 1979 without bone cement. They articulated with ceramic femoral heads mounted on mental femoral stems. After a mean elapsed period of 144 months, 59 sockets were radiographically stable but two showed early signs and six showed late signs of loosening. Four of the loose sockets have been revised. Histological analysis of the retrieved tissue showed a fibrous membrane around all the implants, with fibrocartilage in some. There was no bone ingrowth, and the fibrous membrane was up to 6 mm thick and infiltrated with lymphocytes, plasma cells, and macrophages. Intra- and extracellular birefringent wear particles were seen. Tribological analysis showed total wear rates in two retrieved alumina-on-alumina joints of 2.6 microns per year in a stable implant and 68 microns in a loose implant. Survival analysis showed a revision rate of 12.4% at 136 months.

Long-term results of uncemented alumina acetabular implants

We report the clinical and tribological performance of 67 ceramic acetabular prostheses implanted between 1976 and 1979 without bone cement. They articulated with ceramic femoral heads mounted on mental femoral stems. After a mean elapsed period of 144 months, 59 sockets were radiographically stable but two showed early signs and six showed late signs of loosening. Four of the loose sockets have been revised. Histological analysis of the retrieved tissue showed a fibrous membrane around all the implants, with fibrocartilage in some. There was no bone ingrowth, and the fibrous membrane was up to 6 mm thick and infiltrated with lymphocytes, plasma cells, and macrophages. Intra- and extracellular birefringent wear particles were seen. Tribological analysis showed total wear rates in two retrieved alumina-on-alumina joints of 2.6 microns per year in a stable implant and 68 microns in a loose implant. Survival analysis showed a revision rate of 12.4% at 136 months.