Supply chain diversity buffers cities against food shocks.

Food supply shocks are increasing worldwide1,2, particularly the type of shock wherein food production or distribution loss in one location propagates through the food supply chain to other locations3,4. Analogous to biodiversity buffering ecosystems against external shocks5,6, ecological theory suggests that food supply chain diversity is crucial for managing the risk of food shock to human populations7,8. Here we show that boosting a city's food supply chain diversity increases the resistance of a city to food shocks of mild to moderate severity by up to 15 per cent. We develop an intensity-duration-frequency model linking food shock risk to supply chain diversity. The empirical-statistical model is based on annual food inflow observations from all metropolitan areas in the USA during the years 2012 to 2015, years when most of the country experienced moderate to severe droughts. The model explains a city's resistance to food shocks of a given frequency, intensity and duration as a monotonically declining function of the city's food inflow supply chain's Shannon diversity. This model is simple, operationally useful and addresses any kind of hazard. Using this method, cities can improve their resistance to food supply shocks with policies that increase the food supply chain's diversity.

Be a Lighthouse for Your Medical Students: How to Help Them Navigate During Changing Times to a Successful Match.

The transition between medical school and residency is a complex, multifaceted process that is commonly a time of stress and uncertainty for medical students. Occupying most of a student's final year of medical school, the residency application includes a primary Electronic Residency Application Service application, a variable number of program-specific secondary applications, and interviews. The application process culminates with The Match. Orthopaedic surgery is among the more competitive specialties; thus, it is critical that all involved parties understand the complexity of the process and the numerous variables that play into such a critical decision point in the career trajectory of a future physician. It is important to provide a mentor with an overview of the residency application process, specifically with respect to orthopaedic surgery, so that they may be best prepared to guide their medical student mentee through the process and help them find success.

Do You Really Need a Hand Surgeon? Distal Radius Fractures.

Distal radius fractures are one of the most common injuries treated by orthopaedic surgeons. As the number of distal radius fractures grows and practice patterns demonstrate more of these fractures are treated surgically, it is incumbent for orthopaedic surgeons to understand the fundamentals of evaluation, treatment, and rehabilitation.

Building Blocks of Wellness: Where Do We Start When Our Tasks Have No End?

Surgeon wellness, and the means by which it may be realized, has recently come to the forefront as awareness of burnout among orthopaedic surgeons has increased. Individual surgeons face unique challenges toward finding their own path to thrive. It is important to incorporate varying perspectives regarding potential solutions to surgeons' stresses in both work and extracurricular life. Specifically, the goal is to initiate a discussion regarding wellness by providing insight into the challenges facing surgical residents, supplemented with the perspectives of women and minorities within the field. Peer coaching plays an essential role in optimizing mental health.

Local and Systemic Nail Plate Abnormalities: A Clinical Review.

Nail disorders are often difficult to recognize and diagnose because of the subtlety of their presentation and their shared overlapping features that are common to several conditions. Experientially, this is further complicated by the fact that specific training on diagnosis of nail pathologies varies substantially across most residency programs and for a majority of medical and surgical specialties. To distinguish these presentations from true, potentially deleterious nail disorders, clinicians should have familiarity with the most commonly occurring nail pathologies and their associations, and use a systematic approach when examining or evaluating alterations in the nails. In the present study, we review the most common clinical disorders affecting the nail apparatus.

Evaluation of A2 and A4 Hand Pulley Repair Using Tendon Graft Rings.

PURPOSE: To compare the mechanical characteristics of A2 and combined A2-A4 pulley repair in the intact and damaged flexor pulley system. METHODS: After control testing, we recorded tendon excursion and flexion of 11 cadaveric fingers after several interventions: (1) complete excision of A2 and A4, (2) repair of the A2 with one ring of tendon graft, (3) repair of the A2 with 2 rings of tendon graft, and (4) repair of the A2 with 2 rings combined with repair the A4 with one ring. RESULTS: At the proximal interphalangeal (PIP) joint, the maximum rotational angle decreased by an average of 30% after complete excision of the A2 and A4 pulleys. This angle was still decreased compared with the control by an average of 25% after one-ring repair at A2, 23% after 2-ring repair at A2, and 17% after 2-ring repair at A2 combined with one-ring repair at A4. At the metacarpophalangeal joint, the average maximum rotational angle decreased by an average of 17% after complete excision of the A2 and A4 pulleys. This angle was still decreased compared with the control by an average of 11% after one-ring repair at A2, 7% after 2-ring repair at A2, and 4% after 2-ring repair at A2 combined with one-ring repair at A4. Kinematic behavior at the PIP joint with an intact pulley system was most closely approximated by the 3-loop repair. The least similar behavior was with a 2-ring construct at A2. CONCLUSIONS: All repairs increased average flexion at the PIP and metacarpophalangeal joints compared with the unrepaired samples. The 3-ring configuration exhibited a higher recovery of PIP flexion compared with the other repairs. CLINICAL RELEVANCE: Although each repair restored flexion, clinical studies are necessary to evaluate the clinical relevance of the mechanical results of this study.

Clinical Decision Making for a Soft Tissue Hand Mass: When and How to Biopsy.

Evaluation of a hand mass and subsequent surgical treatment is a frequent clinical encounter for the practicing hand surgeon. The clinical evaluation of benign and malignant hand tumors has traditionally focused on diagnosis, surgical excision, and reconstruction. There is a paucity of literature discussing the determining factors for a hand mass biopsy, its appropriate technique, and postbiopsy preparation and handling. This review discusses the approaches of the hand surgeon and orthopedic oncologist to a soft tissue mass in the hand and clarifies the term biopsy. Special attention is focused on preoperative decisions and indications for core needle, incisional, and excisional biopsies of hand masses. In addition, we include a discussion of surgical technique for obtaining a specimen, processing a specimen, and sending a specimen for pathological evaluation. This highlights specimen labeling and type of fixative utilized for pathological evaluation. This review features a section detailing clinical strategies to reduce morbidity associated with evaluation and treatment of benign and malignant hand masses and is based on recommendations from a synopsis of expert opinion and literature review.

Radiation Exposure to the Orthopaedic Surgeon and Efficacy of a Novel Radiation Attenuation Product.

The purpose of this study was to examine the intraoperative radiation dosage to different body parts and to determine the effectiveness of a new lightweight radiation-attenuating fabric (XPF) versus lead, the current standard. For 51 cases involving fluoroscopy, one attending orthopaedic surgeon wore a set of three dosimeters at various locations. Per each set of three, one dosimeter was shielded with a swatch of XPF, one was placed underneath the lead apron, and one was left exposed. The total dose of radiation was tabulated per body site and the percent attenuation was calculated for both XPF and lead. There was no statistically significant difference in the percent of radiation attenuation by lead and XPF (p = .47). The use of XPF produced 57.83% reduction in weight compared with lead when adjusting for total surface body area. XPF can be used for operating room personnel and patients, providing effective protection from radiation. (Journal of Surgical Orthopaedic Advances 26(4):246-249, 2017).

Predicting Metacarpal Anatomic Lengths via Adjacent Metacarpals.

Purpose: The purpose of this study is to generate validated prediction rules for metacarpal lengths that can be applied without the need for computation tools to assist with restoration of anatomic length after fracture and utilizes only ipsilateral metacarpals. Methods: The anatomic lengths of all hand bones in 50 hands (25 men, 25 women) were used along with linear regression subset analysis to determine which metacarpals are the most predictive of each other. The most predictive metacarpals were then used to generate simple addition and subtraction prediction rules via simplifying the linear equation generated with linear regression analysis. Those rules were then applied to subsequent test cases, and percent accuracy within various cutoffs were analyzed and compared to the accuracy when using the contralateral side. Results: The prediction rules were generated and were found to be identical for both men and women. When applied to the test cases, the estimated metacarpal lengths were within 3 mm of the actual value in 97.5% of the cases for women and 90% of the cases for men compared to 95% when using the contralateral side. Conclusion: The simple additional and subtraction rules generated in this analysis were as good as or superior to using the contralateral side in all cases for women and were as good as or superior to using the contralateral side in for metacarpals 3-5 for men. Clinical Relevance: Using these simple estimating rules may be superior to using the contralateral side in most cases and provides a secondary method for determining anatomic lengths when contralateral radiographs are not available or when contralateral radiographs were obtained in different enough conditions such that the lengths may not be representative of the hand of interest.

Education, Language, and Cultural Concordance Influence Patient-Physician Communication in Orthopaedics.

BACKGROUND: Orthopaedic surgery has a diversity gap, as it is not representative of the racial or sex proportions of the U.S. population. This gap can lead to communication barriers stemming from health literacy, language proficiency, or cultural discordance that may contribute to current health inequities. This study assesses the influence of educational attainment, language, and cultural concordance on patient-physician communication. METHODS: In this cross-sectional study, 394 patients from an urban orthopaedic clinic were administered a Likert-type survey regarding race or ethnicity, educational level, communication, patient satisfaction, language proficiency, and culture. One-way analysis of variance, chi-square tests, and Welch t tests were used to evaluate responses. RESULTS: The majority of subjects identified as African-American/Black (50%) or Hispanic/Latino (30%). Completing high school was associated with a better ability of the subjects to communicate with their orthopaedic surgeon (p < 0.001). Hispanic subjects reported lower English proficiency (p < 0.001) and decreased ability to communicate with their physician (p < 0.001) compared with other subjects, with educational attainment influencing their ability to understand their orthopaedic surgeon in English (p < 0.001). African-American and Hispanic patients placed greater importance on orthopaedic surgeons understanding their culture than White patients (p < 0.001). Hispanic patients who saw a language and culture-concordant surgeon valued having a Spanish-speaking surgeon more than Hispanic patients who did not see a concordant surgeon (p = 0.04). CONCLUSIONS: These results suggest that patient-physician language concordance, particularly in patients with lower education, may be essential to delivering high-quality patient care. Hispanic and African-American patients placed significantly greater importance on their orthopaedic surgeons understanding their culture. Hispanic patients frequently sought care with language-concordant surgeons and placed higher value on physicians understanding their culture. To better serve minority communities, efforts should be made to increase orthopaedic surgeons' cultural humility and to recruit a diverse multilingual surgeon workforce. CLINICAL RELEVANCE: This research demonstrates that cultural and language concordance, specifically between Hispanic patients and Hispanic, Spanish-speaking surgeons, can significantly enhance patient preference and potentially improve patient satisfaction and outcomes in orthopaedic care. Additionally, it underscores the importance of understanding and addressing the diversity within the field and the patient population to better meet the needs of a multicultural society.

Acute Carpal Tunnel Syndrome from Horseshoe Abscess: A Case Report.

CASE: A 53-year-old man presented with a puncture wound to his right thumb, resulting in a horseshoe abscess, its infectious clinical picture muddled by dense paresthesias from the ensuing acute carpal tunnel syndrome. He was treated with irrigation and debridement of the thumb and small finger flexor tendon sheaths, carpal tunnel release, and bootlacing and dermal substitute application to the proximal forearm with eventual split-thickness skin grafting. CONCLUSION: Although a horseshoe abscess resulting in acute carpal tunnel syndrome is a rare entity unquantified in the literature, the treating orthopaedic surgeon should be aware of its association and initiate appropriate treatment accordingly.

Cities can benefit from complex supply chains.

Supply chain complexity is perceived to exacerbate the supply disruptions or shocks experienced by a city. Here, we calculate two network measures of supply chain complexity based on the relative number-horizontal complexity-and relative strength-vertical complexity-of a city's suppliers. Using a large dataset of more than 1 million annual supply flows to 69 major cities in the United States for 2012-2015, we show that a trade-off pattern between horizontal and vertical complexity tends to characterize the architecture of urban supply networks. This architecture shapes the resistance of cities to supply chain shocks. We find that a city experiences less intense shocks, on average, as supplier relative diversity (horizontal complexity) increases for more technologically sophisticated products, which may serve as a mechanism for buffering cities against supply chain shocks. These results could help cities anticipate and manage their supply chain risks.

Dementia and Hip Fractures: A Comprehensive Review of Management Approaches.

¼ The elderly population is the fastest growing demographic, and the number of dementia cases in the United States is expected to double to 10 million by 2050.¼ Patients with dementia are at 3× higher risk of hip fractures and have higher morbidity and mortality after hip fractures.¼ Hip fracture patients with dementia benefit from early analgesia and timely surgical fixation of fracture.¼ Early and intensive inpatient rehabilitation is associated with improved postoperative outcomes in patients with dementia.¼ Coordination of care within a "orthogeriatric" team decreases mortality, and fracture liaison services show potential for improving long-term outcomes in hip fracture patients with dementia.

The Effect of Metacarpal Shortening on Finger Strength and Joint Motion: A Cadaveric Biomechanical Study.

Purpose: Discrepancies exist between previous biomechanical and clinical studies when determining acceptable metacarpal shortening after metacarpal fractures. This study aimed to determine the amount of acceptable shortening after a metacarpal fracture before finger motion and strength is compromised. Methods: We defrosted ten fresh-frozen cadaveric hands. A screw-driven external fixator was placed to stabilize the metacarpal, then a 15.0-mm section of the index metacarpal was excised and replaced with a three dimensional-printed, custom-designed polyethylene insert. The hand was then mounted on a custom testing rig, and the index finger was flexed using the flexor digitorum profundus tendon. Joint angles and fingertip force were recorded as the finger was flexed. Incrementally smaller inserts were placed, and testing was repeated. Results: The average joint angles of the intact condition for the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints were (54 [SD = 13], 79 [SD = 21], and 73 [SD = 10]), respectively. There were no statistically significant changes to any joint angle with any amount of shortening. The maximal fingertip contact pressures were 41 N (17), 31 N (12), 24 N (14), 19 N, (11), and 14 N (8) for the 15 mm, 12.5 mm, 10 mm, 7.5 mm, and 5 mm inserts, respectively. All changes in fingertip force by insert size were statistically significant. Conclusion: Metacarpal shortening does not affect flexion range of motion regardless of the amount of shortening, but it significantly affects finger strength. The loss of strength after shortening was approximately 6.5% per mm of shortening for the fractured metacarpal. Clinical Relevance: When viewed in the context of the hand as a whole and the contribution of the index finger to grip being only 23.5%, it is unlikely that any shortening will significantly affect the average patient regarding grip strength. However, for a patient who requires fine motor strength, any amount of shortening may affect their finger function and needs to be addressed.

The Interaction of Diabetic Peripheral Neuropathy and Carpal Tunnel Syndrome.

BACKGROUND: Diabetes mellitus (DM) increases the risk for carpal tunnel syndrome (CTS) and is associated with its own neuropathic complications. Diabetic peripheral neuropathy (DPN) is a common complication seen in diabetic patients. In this study, we examine the relationship between the severity of DPN and CTS. METHODS: Type 2 diabetic and control patients (n = 292) were recruited at a clinic visit. The Michigan Neuropathy Screening Instrument (MNSI) questionnaire was used to collect data related to peripheral neuropathy. The MNSI scores were compared for patients with CTS with and without DM in univariable and multivariable analyses. χ2 analyses were performed to quantitatively measure the associations between peripheral neuropathy and the presence of CTS. RESULTS: Of the 292 patients, 41 had CTS, and 19 of these had both CTS and DM. Of the 138 diabetic patients, 85 had peripheral neuropathy. There was no association between a diagnosis of CTS and an MNSI score indicative of peripheral neuropathy. In the diabetic population, CTS was inversely associated with DPN (P = .017). The MNSI scores between diabetic and control patients with CTS were comparable. CONCLUSION: The severity of peripheral neuropathy in diabetic patients with and without CTS is comparable. Diabetic patients without peripheral neuropathy have an association with higher incidence of CTS in this study, suggesting that there are disparate mechanisms causing DPN and CTS. Nevertheless, diabetes and CTS are risk factors for developing the other, and future studies should further explore how DPN and CTS differ to tailor patient interventions based on their comorbidities.

Ligamentous and capsular injuries to the metacarpophalangeal joints of the hand.

The mechanism of dorsal dislocation of the metacarpophalangeal (MCP) joint is with forced hyperextension of the joint and the main structure injured is the volar plate. A simple dislocation can be reduced by closed means whereas a complex dislocation cannot. Care must be taken not to put traction across the joint, which may cause the volar plate to slip into the joint, converting a simple dislocation into a complex dislocation. Volar dislocations are rare and mainly treated nonoperatively. Sagittal band injuries can be treated with extension splinting or surgical management with direct repair or reconstruction. A locked MCP joint can usually be treated with closed manipulation. This article discusses these injuries and management options.

Median Nerve Mononeuropathy and Meralgia Paresthetica After Prone Positioning in a Patient with COVID-19 ARDS: A Case Report.

CASE: Throughout the COVID-19 pandemic, prone positioning has decreased mortality in patients with severe acute respiratory distress syndrome. We present the unique case of a patient who developed left median nerve mononeuropathy and bilateral meralgia paresthetica after prone positioning while afflicted with COVID-19. These nerve injuries have been rarely reported in the literature and never before in the same patient. CONCLUSION: Our case highlights the importance of increased care when positioning patients prone by padding bony prominences, evenly distributing pressure across known sites of peripheral nerve entrapment, and giving consideration to prone-positioning time intervals when caring for intubated patients.

The Anesthetic Effectiveness of J-Tip Needle-Free Injection System Prior to Trigger Finger Injection: A Double-Blind Randomized Clinical Trial.

Background: The aim of this preliminary study was to evaluate the effectiveness of a J-tip needle-free injection system (JNFS) to reduce pain associated with corticosteroid injection of the tendon sheath for treatment of trigger finger. Methods: Thirty-four consecutive trigger fingers occurring in 28 unique patients who met inclusion/exclusion criteria were consented and enrolled into this double-blind randomized controlled study. Patients were randomly assigned to the control (JNFS loaded with sterile normal saline) or treatment group (JNFS loaded with buffered 1% lidocaine). Both the fellowship-trained hand surgeon and patient were blinded to the allocation group. Prior to each trigger finger injection, each patient rated pain associated with stubbing toe and papercut on the visual analog scale (VAS), in addition to a postprocedure VAS pain score. Results: A total of 28 patients and 34 digits were enrolled in this study. There was no difference in patient demographics or preintervention pain perception between the control and treatment groups. The use of JNFS demonstrated lower mean pain VAS score when comparing the control group (n = 17) with the treatment group (n = 17), with VAS pain scores of 49 (SD = 31) and 39 (SD = 36), respectively. However, this difference was not statistically significant (P = .389). Conclusions: The use of JNFS loaded with 1% buffered lidocaine may reduce pain associated with trigger finger injections, although our results did not find a statistically significant difference. We hypothesize that the pain caused by the acidity of lidocaine is the primary driver of pain and discomfort during injection, and the pain from the needle stick is secondary. As a result, any pain reduction from JNFS is masked by the most painful part of injection-the delivery of injectate. Based on the findings and experience obtained from this study, we hypothesize that a follow-up study using buffered lidocaine may be able to better reveal the benefits of JNFS.

Integrating embedded resources and network analysis to understand food-energy-water nexus in the US.

To find a sustainable way of supplying food, energy, and water (FEW) while simultaneously protecting the ecosystem services, it is imperative to build greater understanding on interconnections, feedback, and dependencies in FEW systems. The FEW nexus has developed as a field of study to provide frameworks for such pursuits. Building upon previous work in this paper, we analyze FEW resources through the development of a virtual water trade network using the US network of food and energy flows and their associated virtual water contents. Our main objective is to provide a quantitative estimation of the virtual water embodied in the internal US food and energy transfers and analyze the associated interdependencies of these connections. Three methodological advancements demonstrate the novelty of this work. First, unlike existing FEW virtual water modeling studies, our work separates corn into both food and energy resources accounting for the significant use of corn for ethanol in the United States. Second, we apply recently published water consumption values for energy commodities confirming the variation between previous water footprint studies and these more accurate accounting procedures. Third, we examine network properties of the trade flows furthering FEW nexus literature and showcasing avenues for future research. Our results indicate that accounting for the transfer of corn from the food commodity network to the energy commodity network leads to a virtual water footprint decline of 11% for the cereal grain virtual water network. Additionally, the food trade network shows highly dense and connected properties compared to the energy trade network. Finally, our results indicate that transfers of water footprints between water scarce and water abundant states differ substantially between food and energy virtual water networks. A quantifiable understanding of the water footprint network embodied in the food and energy trade can help in developing policies for promoting conservation and efficiency in the context of the FEW nexus.

Fragility of a multilayer network of intranational supply chains.

Supply chains enable the flow of goods and services within economic systems. When mapped for the entire economy and geographic locations of a country, supply chains form a spatial web of interactions among suppliers and buyers. One way to characterize supply chains is through multiregional input-output linkages. Using a multiregional input-output dataset, we build the multilayer network of supply chains in the United States. Together with a network cascade model, the multilayer network is used to explore the propagation of economic shocks along intranational supply chains. We find that the effect of economic shocks, measured using the avalanche size or total number of collapsed nodes, varies widely depending on the geographic location and economic sector of origin of a shock. The response of the supply chains to shocks reveals a threshold-like behavior. Below a certain failure or fragility level, the avalanche size increases relatively quickly for any node in the network. Based on this result, we find that the most fragile regions tend to be located in the central United States, which are regions that tend to specialize in food production and manufacturing. The most fragile layers are chemical and pharmaceutical products, services and food-related products, which are all sectors that have been disrupted by the Coronavirus Disease 2019 (COVID-19) pandemic in the United States. The fragility risk, measured by the intersection of the fragility level of a node and its exposure to shocks, varies across regions and sectors. This suggests that interventions aiming to make the supply-chain network more robust to shocks are likely needed at multiple levels of network aggregation.