Factors associated with increased 30-day re-operation risk in anterior cruciate ligament reconstruction.

BACKGROUND: Revision surgery following isolated anterior cruciate ligament reconstruction (ACLR) has often focused on mid- to long-term revisions due to re-rupture, while short-term 30-day revision is a rare, but underappreciated entity. This study aims to characterize incidence and risk factors for reoperations following isolated ACLR. METHODS: This is a retrospective case-control analysis of the American College of Surgeons National Surgical Quality Improvement Program Database (NSQIP) database from 2005 to 2017. Current Procedural Terminology codes were used to identify elective isolated ACLR patients. Patients undergoing reoperations were analyzed using bivariate analysis against their respective perioperative variables. Multivariate stepwise logistic regression was used to identify independent risk factors for reoperations after ACLR. RESULTS: 12,790 patients were included in the study. 37.0% of patients were female. Mean age was 32.2+/-10.7 years and mean body mass index (BMI) was 27.8+/-6.5 kg/m2, with 28.9% of patients with BMI > 30. The most frequently reported reason for reoperation based on CPT and ICD-9/10 codes was postoperative infection (0.5%). Overall reoperation rate was approximately 0.5%. Multivariate analysis identified operative time >1.5 h (OR 2.6 [95% CI; 1.5-4.4]), dependent functional status (OR 14.0 [1.4-141.6]), and adjunctive anesthesia (OR 2.4 [95% CI; 1.1-5.0]) as independent risk factors for reoperation. Female sex was a protective factor against reoperations (OR 0.6 [0.3-0.98]). CONCLUSION: Primary, isolated ACLR is associated with extremely low rates of short-term reoperations. Operative time >1.5 h, dependent functional status, and adjunctive anesthesia were independent risk factors for reoperation and female sex was a protective factor against reoperation. LEVEL OF EVIDENCE: Level III. Retrospective cohort study.

Ex Vivo Drug Sensitivity Correlates with Clinical Response and Supports Personalized Therapy in Pediatric AML.

Acute myeloid leukemia (AML) is a heterogeneous disease that accounts for ~20% of all childhood leukemias, and more than 40% of children with AML relapse within three years of diagnosis. Although recent efforts have focused on developing a precise medicine-based approach towards treating AML in adults, there remains a critical gap in therapies designed specifically for children. Here, we present ex vivo drug sensitivity profiles for children with de novo AML using an automated flow cytometry platform. Fresh diagnostic blood or bone marrow aspirate samples were screened for sensitivity in response to 78 dose conditions by measuring the reduction in leukemic blasts relative to the control. In pediatric patients treated with conventional chemotherapy, comprising cytarabine, daunorubicin and etoposide (ADE), ex vivo drug sensitivity results correlated with minimal residual disease (r = 0.63) and one year relapse-free survival (r = 0.70; AUROC = 0.94). In the de novo ADE analysis cohort of 13 patients, AML cells showed greater sensitivity to bortezomib/panobinostat compared with ADE, and comparable sensitivity between venetoclax/azacitidine and ADE ex vivo. Two patients showed a differential response between ADE and bortezomib/panobinostat, thus supporting the incorporation of ex vivo drug sensitivity testing in clinical trials to further evaluate the predictive utility of this platform in children with AML.

Eliciting Activity Goals With a Self-Administered Survey Among Patients With Hip or Knee Osteoarthritis.

Background: Success of treatment for hip or knee osteoarthritis (OA) should be evaluated relative to patients' personal activity goals. Questions/Purposes: We sought to ascertain important principles for collecting such goals and developed a survey informed by those principles to facilitate better shared decision-making. Methods: From a series of 100 patient interviews inquiring about specific activity goals, we identified 6 principles for goal collection that are important to patients and physicians and could practically facilitate better shared decision-making (phase 1). Incorporating these principles, we designed a self-administered survey to measure specific pretreatment activity goals, piloting in 1 surgeon's office (phase 2). During office visits, the feasibility of achieving stated goals was discussed between the surgeon and the patient, and goal modifications were recorded. Results: The phase 2 survey was administered to 252 patients, among whom 130 were women (51.6%); 215 (85.3%), white; mean age, 58.5 years; mean body mass index, 30.2 kg/m2; and 92.9% had 1 or more goals, totaling 106 unique goals. Patient demographics were associated with having goals for walking, running, exercising, golfing, tennis, and stairs. Hip and knee patients could last perform their goal on average 21.7 and 38.6 months prior (P = .002). Patient and surgeon agreed to modify goals 19% of the time, more often among younger patients (P = .001) and for running (64% modified, P < .0001) and skiing (42%, P = .0026), but less often for walking (14%, P = .0430) and golf (0%, P = .0204). Conclusions: Patients' activity goals can be captured by a self-administered survey, collected before an office visit, and used to facilitate shared decision-making.

Biosynthesis and characterization of fuscimiditide, an aspartimidylated graspetide.

Microviridins and other ω-ester-linked peptides, collectively known as graspetides, are characterized by side-chain-side-chain linkages installed by ATP-grasp enzymes. Here we report the discovery of a family of graspetides, the gene clusters of which also encode an O-methyltransferase with homology to the protein repair catalyst protein L-isoaspartyl methyltransferase. Using heterologous expression, we produced fuscimiditide, a ribosomally synthesized and post-translationally modified peptide (RiPP). NMR analysis of fuscimiditide revealed that the peptide contains two ester cross-links forming a stem-loop macrocycle. Furthermore, an unusually stable aspartimide moiety is found within the loop macrocycle. We fully reconstituted fuscimiditide biosynthesis in vitro including formation of the ester and aspartimide moieties. The aspartimide moiety embedded in fuscimiditide hydrolyses regioselectively to isoaspartate. Surprisingly, this isoaspartate-containing peptide is also a substrate for the L-isoaspartyl methyltransferase homologue, thus driving any hydrolysis products back to the aspartimide form. Whereas an aspartimide is often considered a nuisance product in protein formulations, our data suggest that some RiPPs have aspartimide residues intentionally installed via enzymatic activity.

Analysis of the Quality, Reliability, and Educational Content of YouTube Videos Concerning Spine Tumors.

BACKGROUND: Given the high volume of user traffic to YouTube, it is important that the medical information disseminated on this platform is of high quality. Unfortunately, previous studies have demonstrated this to not be the case. We aimed to evaluate the quality and educational content of YouTube videos concerning spine tumors using 2 previously validated assessment tools. METHODS: The first 50 videos returned by the keyword search "spine tumor" were included in the study. The JAMA benchmark criteria (range: 0-4) were used to assess video reliability, whereas the Global Quality Score (GQS) (range: 0-5) was used to determine educational quality and content. RESULTS: Videos were primarily authored by academic medical groups (80%), while content was primarily related to disease-specific information (44%) or the patient experience (24%). Surgical treatment options and nonsurgical management were discussed in 66% and 50% of all videos, respectively. Sixty percent of videos reported benefits of treatment, while 44% reported potential risks or complications. The average JAMA score and GQS were 3.1 ± 0.27 (range: 3-4) and 2.6 ± 1.3 (range: 1-5), respectively. Multivariate linear regression analyses revealed that video duration (ß = 0.00697, P = 0.04) and number of views (ß = 0.000018, P = 0.001) were positively associated with JAMA score. Video duration and number of dislikes were associated with higher GQS (ß = 0.041, P = 0.025) and lower GQS (ß = -0.189, P = 0.04), respectively. Lastly, number of days since upload was associated with lower Video Power Index (ß = -0.003, P = 0.003). CONCLUSIONS: The reliability, quality, and educational content of YouTube videos were poor to suboptimal. Physicians should be wary of the education provided by YouTube on spine tumors and guide patients in seeking out additional sources of information. CLINICAL RELEVANCE: YouTube videos are commonly viewed by patients seeking health information on spine tumors. While certain videos may provide useful information, the absence of an editorial process allows videos with poor reliability and low quality to be uploaded. We believe these findings may be useful to physicians seeking ways to better guide their patients with the most appropriate educational tools throughout their disease management.

Patient Reported Outcomes in Metastatic Spine Disease: Concurrent Validity of PROMIS with the Spine Oncology Study Group Outcome Questionnaire.

STUDY DESIGN: Cross-sectional prospective study. OBJECTIVE: To evaluate the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF), Pain Interference (PI), and Depression domains in comparison to the Spine Oncology Study Group-Outcomes Questionnaire (SOSG-OQ) in patients with metastatic spine disease. SUMMARY OF BACKGROUND DATA: While there remains a significant movement toward incorporating patient-reported outcome measures (PROMs) into clinical care, there are few validated PROMs for patients with metastatic spine disease. The SOSG-OQ was designed and validated for metastatic spine tumor patients. However, the use of general symptom-based PROMs, such as PROMIS domains, may reduce both patient and physician burden and improve interdisciplinary care if shown to be concurrently valid. METHODS: Metastatic spine tumor patients from January 2017 to July 2021 at a single academic medical center were asked to complete PROMIS PF, PI, and Depression domains and the SOSG-OQ. Spearman correlation (p) coefficients were calculated. RESULTS: A total of 103 unique visits, representing 79 patients met our inclusion criteria. A majority were men (59; 57%) and Caucasian (93; 90%), and the average age was 64-years-old (range: 34-87). There were 13 different types of histologies reported, with multiple myeloma, breast cancer, and prostate cancer representing 28 (27%), 26 (25%), and 13 (13%), respectively. Additional cancers included renal cell carcinoma, lung cancer, colon cancer, thyroid cancer, large B-cell lymphoma, nonHodgkin lymphoma, esophageal cancer, plasmacytoma, metastatic paraganglioma, and metastatic spindle cell sarcoma. SOSG-OQ was strongly correlated with PROMIS PI (ρ = 0.78) and PROMIS PF (ρ = 0.71), and moderately correlated with PROMIS Depression (ρ = 0.58). CONCLUSION: PROMIS PF, PI, and Depression appear to capture similar clinical insight as the SOSG-OQ. Spine surgeons can consider using these PROMIS domains in lieu of the SOSG-OQ in metastatic spine tumor patients.Level of Evidence: NA.

Presenteeism and absenteeism before and after single-level lumbar spine surgery.

BACKGROUND CONTEXT: Health can impact work performance through absenteeism, time spent away from work, and presenteeism, inhibited at-work performance. Low back pain is common and costly, both in terms of direct medical expenditures and indirect reduced work performance. PURPOSE: Surgery for lumbar spinal pathology is an important part of treatment for patients who do not respond to nonsurgical management. While the indirect costs of return to work and absenteeism among employed patients undergoing lumbar spine surgery have been studied, little work has been done to quantify presenteeism before and after lumbar spine surgery. STUDY DESIGN/SETTING: Prospective cohort study at a single high-volume urban musculoskeletal specialty hospital. PATIENT SAMPLE: Patients undergoing single-level lumbar spinal fusion and/or decompression surgery. OUTCOME MEASURES: Presenteeism and absenteeism were measured using the World Health Organization's Health and Work Performance Questionnaire before surgery, as well as 6 weeks, 6 months, and 12 months after surgery. METHODS: Average presenteeism and absenteeism were evaluated at pre-surgical baseline and each follow-up timepoint. Monthly average time lost to presenteeism and absenteeism were calculated before surgery and 12 months after surgery. Study data were collected and managed using REDCap electronic data capture tools with support from Clinical and Translational Science Center grant, UL1TR002384. One author discloses royalties, private investments, consulting fees, speaking/teaching arrangements, travel, board of directorship, and scientific advisory board membership totaling >$300,000. RESULTS: We enrolled 134 employed surgical patients, among whom 115 (86%) responded at 6 weeks, 105 (78%) responded at 6 months, and 115 (86%) responded at 12 months. Preoperatively, mean age was 56.4 years (median 57.5), and 41.0% were women; 68 (50.7%) had only decompressions, while 66 (49.3%) had fusions. Among respondents at each time point, 98%, 92%, and 92% were still employed, among whom 76%, 96%, and 96% had resumed working, respectively (median 29 days). Average at-work performance among working patients (who responded at each pair of timepoints) moved from 75.4 to 78.7 between baseline and 6 weeks, 71.8 to 85.9 between baseline and 6 months, and 73.0 to 88.1 between baseline and 12 months. Gains were concentrated among the 52.0% of patients whose at-work performance was declining (and low) leading up to surgery. Average absenteeism was relatively unmoved between baseline and each follow-up. Before surgery, the monthly average time lost to presenteeism and absenteeism was 19.8% and 18.9%, respectively; 12 months after surgery, these numbers were 9.7% and 16.0%; changes represent a mitigated loss of 13.0 percentage points of average monthly value. CONCLUSIONS: Presenteeism and absenteeism contributed roughly evenly to preoperative average monthly lost time. Although average changes in absenteeism and 6-week at-work performance were small, average changes in at-work performance at 6 and 12 months were significant. Cost-benefit analyses of lumbar spine surgery should therefore consider improved presenteeism, which appears to offset some of the direct and indirect costs of surgical treatment.

Assessing Factors Associated With Altmetric Attention Score: A Preliminary Study of 3 Hand Surgery Journals.

BACKGROUND: Traditional measures of evaluating scholarly output do not capture the impact social media can provide in disseminating and promoting research. We sought to better understand the level of online attention that high-quality hand research received. METHODS: Scientific manuscripts published from 2017 in Journal of Hand Surgery (American Volume) (JHS-A), Journal of Hand Surgery (European Volume) (JHS-E), and HAND were recorded. Manuscript characteristics were determined, including the number of citations. Altmetric Attention Score (AAS), a measure of a manuscript's online attention and impact, was determined, as well as Twitter mentions, Facebook mentions, and news outlet mentions. Spearman rho (ρ) correlation coefficient was used to evaluate the relationship between the number of citations and AAS. Multivariable linear regression analysis was performed to determine which manuscript factors were associated with AAS. RESULTS: A total of 323 manuscripts were identified. There was a weak positive correlation between the number of citations and AAS; however, this relationship did not exist for each individual journal. Publication in HAND and JHS-E were associated with lower average manuscript AAS when using JHS-A as the reference group. Two additional factors were also associated with increased manuscript AAS: (1) being a clinical study focused on a specific upper extremity anatomical location; and (2) increasing number of institutions on a study. CONCLUSIONS: Publication in HAND and JHS-E were associated with lower manuscript AAS when using JHS-A as the reference group, suggesting that HAND and JHS-E have room for improvement in using social media to share their high-quality hand surgery scientific articles.

Altmetric Attention Score: Evaluating the Social Media Impact of Burn Research.

Traditional measures of scholarly impact (ie, impact factor, citation rate) do not account for the role of social media in knowledge dissemination. The Altmetric Attention Score (AAS) tracks the online sharing activity of articles on platforms such as Twitter and Facebook. All 285 original scientific articles published in Journal of Burn Care & Research and Burns from January to December 2017 were obtained from official journal websites. Article characteristics extracted include AAS; number of Twitter, Facebook, and news outlet mentions; subject of study and study design; number of citations; number of authors and academic institutions; and others. The average AAS for all articles was 6.1 (SD: 48; range: 0 to 611) in which 156 (55%) of those had Twitter mentions. The mean AAS for Journal of Burn Care & Research and Burns were 7.7 (SD: 54; range: 0 to 536) and 5.3 (SD: 45; range: 0 to 611), respectively. There was a weak, positive correlation between AAS and citation count for all articles (ρ = 0.12; P = .049), and this finding was consistent for Journal of Burn Care & Research (ρ = 0.21; P = .039) and Burns (ρ = 0.15; P = .038) individually. The weak correlation between the two metrics supports that AAS and citation count capture the attention of different audiences. In addition, studies discussing skin grafting were associated with higher average AAS (ß: 29 [95% CI: 4.2 to 54]; P = .022). Overall, our findings support using both AAS and traditional bibliometrics to assess article impact.

Manuscript characteristics associated with the altmetrics score and social media presence: an analysis of seven spine journals.

BACKGROUND CONTEXT: Impact factor, citation rate, and other traditional measures of scholarly impact do not account for the role that social media has in the dissemination of research. The Altmetric Attention Score (AAS) quantifies the active online presence of individual articles on various platforms (eg, Twitter, Facebook). PURPOSE: We sought to better understand the factors associated with greater online attention and AAS in seven spine journals. STUDY DESIGN/SETTING: Cross-sectional study. PATIENT SAMPLE: No patients were included in this study. We analyzed 380 articles in seven major spine journals. OUTCOME MEASURES: Extracted manuscript characteristics included AAS; number of Twitter, Facebook, and news outlet mentions; number of citations, references, academic institutions, and authors; and sample size, geographic region, subject of study, and level of evidence. METHODS: All original scientific manuscripts published in the official January, February, and March 2017 issues of Spine, The Spine Journal, Spine Deformity, Journal of Neurosurgery-Spine, Clinical Spine Surgery, Global Spine Journal, and European Spine Journal were identified. The correlation of AAS and number of citations was determined by Spearman's Rho (ρ) correlation coefficient. Manuscript factors associated with AAS were determined by a multivariable linear regression analysis. RESULTS: A total of 380 manuscripts were included in the analysis. The average AAS across all seven journals was 4.9 (SD: 19.4; Range: 0-356), with the highest average AAS reported for The Spine Journal at 8.0 (SD: 13; Range: 0-60). There was a weak, positive correlation between AAS and number of citations (ρ = .32; p < .05); this relationship was individually present for four out of the seven included journals. In addition, number of references was associated with higher average manuscript AAS (ß: 0.16 [95% CI: 0.002-0.32]; p < .05). No manuscript characteristics were associated with lower AAS. CONCLUSIONS: Our analysis of seven spine journals revealed a weak, positive correlation between AAS and number of citations. Number of references was associated with higher AAS. We believe these findings may be useful to authors seeking ways to maximize the impact of their research.

Presenteeism and Absenteeism Before and After Total Hip and Knee Arthroplasty.

BACKGROUND: Absenteeism is costly, yet evidence suggests that presenteeism-illness-related reduced productivity at work-is costlier. We quantified employed patients' presenteeism and absenteeism before and after total joint arthroplasty (TJA). METHODS: We measured presenteeism (0-100 scale, 100 full performance) and absenteeism using the World Health Organization's Health and Work Performance Questionnaire before and after TJA among a convenience sample of employed patients. We captured detailed information about employment and job characteristics and evaluated how and among whom presenteeism and absenteeism improved. RESULTS: In total, 636 primary, unilateral TJA patients responded to an enrollment email, confirmed employment, and completed a preoperative survey (mean age: 62.1 years, 55.3% women). Full at-work performance was reported by 19.7%. Among 520 (81.8%) who responded to a 1-year follow-up, 473 (91.0%) were still employed, and 461 (88.7%) had resumed working. Among patients reporting at baseline and 1 year, average at-work performance improved from 80.7 to 89.4. A Wilcoxon signed-rank test indicated that postoperative performance was significantly higher than preoperative performance (P < .0001). The percentage of patients who reported full at-work performance increased from 20.9% to 36.8% (delta = 15.9%, 95% confidence interval = [10.0%, 21.9%], P < .0001). Presenteeism gains were concentrated among patients who reported declining work performance leading up to surgery. Average changes in absences were relatively small. Combined, the average monthly value lost by employers to presenteeism declined from 15.3% to 8.3% and to absenteeism from 16.9% to 15.5% (ie, mitigated loss of 8.4% of monthly value). CONCLUSION: Among employed patients before TJA, presenteeism and absenteeism were similarly costly. After, employed patients reported increased performance, concentrated among those with declining performance leading up to surgery.

The Evolving Impact of COVID-19 on Medical Student Orthopedic Education: Perspectives From Medical Students in Different Phases of the Curriculum.

INTRODUCTION: The world-wide lockdown caused by Coronavirus Disease 2019 (COVID-19) has upended the trajectories of lives everywhere. The medical profession has been on the front lines of this rapidly developing situation, which in turn has called for unprecedented changes in the medical school curriculum. These changes have severe implications for medical students interested in applying to competitive surgical specialties like orthopedics. METHODS: As medical students in 3 different class years pursuing orthopedic surgery, we provide our perspectives on the impact that COVID-19 has had on medical student orthopedic education. RESULTS: With the removal of away rotations and a shift to virtual interviews, rising fourth year medical students are arguably the most impacted as they prepare for the orthopedic residency application process. Third year students, who are in the exploratory phase of choosing a specialty, also face uncertainties in the shift to a "new" clerkship experience that may (1) be of shorter duration, (2) implement shifts to limit overcrowding of clinical space, and (3) increase the use of telehealth over direct patient contact. DISCUSSION: The COVID-19 pandemic has altered the course of medical students' orthopedic education in unprecedented ways. We believe the following suggestions may be helpful for students seeking alternative, supplemental ways of learning: (1) read up on major orthopedic journals, (2) reach out to orthopedic surgeons in areas of interest, (3) reach out to program directors/medical clerkship directors/program coordinators for opportunities to attend their educational curriculum virtually, (4) attend online lectures and hospital grand rounds, and (5) practice suturing technique with a practice kit. CONCLUSIONS: While the medical education landscape remains uncertain amid the evolving conditions of COVID-19, as medical students we strive to learn from this pandemic and respond to future unforeseen challenges with resilience, dedication, and compassion: all qualities we admire in orthopedic surgeons.