Racial Disparities in Outcomes After Foot and Ankle Surgery: A Systematic Review and Meta-Analysis.

This systematic review and meta-analysis delved into the impact of race and ethnicity on outcomes following foot and ankle surgery, an area garnering increasing attention within the medical community. Despite significant literature on post-surgical clinical and functional outcomes, limited research has explored the influence of racial and ethnic factors on post-operative outcomes. In this study, data from 33 relevant studies, involving a total of 557,734 patients, were analyzed to assess outcomes across different racial and ethnic groups. Notably, only six studies met the criteria for inclusion in the final meta-analysis due to variations in outcome reporting. Findings revealed disparities in functional scores, pain levels, and resource utilization among different racial and ethnic cohorts. Specifically, non-White and minority patients exhibited higher rates of foot and ankle fractures and lower extremity surgeries, worse functional outcomes, increased pain, longer hospital stays, and a greater incidence of complications compared to their White counterparts. However, some studies presented contradictory results, emphasizing the necessity for further investigation to elucidate these discrepancies fully. This research underscores the importance of considering racial and ethnic factors in foot and ankle surgery outcomes and highlights the need for targeted interventions to address existing disparities.

Promotion of mobility among hospitalised older adults: An exploratory study on perceptions of patients, carers and nurses.

BACKGROUND: Hospitalisation of an older adult due to acute medical illness can result in adverse events and accelerate loss of independence despite recovery from the illness. Promoting mobility during hospitalisation can help to mitigate the risks of functional decline. Understanding the perspectives on the barriers and the maintenance of mobility is essential in the development of effective strategies. AIMS: To explore the perceptions of patients and their carers, as well as the nurses on promotion of mobility among hospitalised adult older patients. METHODS: A qualitative descriptive study design with purposive and convenience sampling approach was undertaken. A total of fourteen patients, six carers and ten nurses from a general medical ward of an acute care tertiary public hospital in Singapore were recruited over the period of November 2017 to February 2018. Face to face semi-structured interviews were conducted and audio-recorded. The interview transcripts were coded and an inductive content analysis approach was adopted to generate categories of sub-themes and themes through the open coding process. RESULTS: Four main themes were generated: (1) perceived and induced fear of falling; (2) challenges in initiation of mobility; (3) influence of premorbid status and physical condition on activity level; and (4) strategies to promote mobility. CONCLUSION: Recognition of the importance of mobility as well as the detrimental effects of prolonged bed rest during hospitalization is an essential first step toward developing successful interventions to promote mobility in the Asian context. Improvements need to be made to help overcome the various barriers and challenges in the mobilization of the older patients in the acute care settings. Nurses and other members of the care team can help to increase the confidence of patients and among family carers (in providing assistance during mobility) by role modelling and provision of walking aids as well as risk-based education.

Variation in Oral Board Examination Accommodations Among Specialties.

Importance: Board certification can have broad implications for candidates' career trajectories, and prior research has found sociodemographic disparities in pass rates. Barriers in the format and administration of the oral board examinations may disproportionately affect certain candidates. Objective: To characterize oral certifying examination policies and practices of the 16 Accreditation Council for Graduate Medical Education (ACGME)-accredited specialties that require oral examinations. Design, Setting, and Participants: This cross-sectional study was conducted from March 1 to April 15, 2023, using data on oral examination practices and policies (examination format, dates, and setting; lactation accommodations; and accommodations for military deployment, family emergency, or medical leave) as well as the gender composition of the specialties' boards of directors obtained from websites, telephone calls and email correspondence with certifying specialists. The percentages of female residents and residents of racial and ethnic backgrounds who are historically underrepresented in medicine (URM) in each specialty as of December 31, 2021, were obtained from the Graduate Medical Education 2021 to 2022 report. Main Outcome and Measures: For each specialty, accommodation scores were measured by a modified objective scoring system (score range: 1-13, with higher scores indicating more accommodations). Poisson regression was used to assess the association between accommodation score and the diversity of residents in that specialty, as measured by the percentages of female and URM residents. Linear regression was used to assess whether gender diversity of a specialty's board of directors was associated with accommodation scores. Results: Included in the analysis were 16 specialties with a total of 46 027 residents (26 533 males [57.6%]) and 233 members of boards of directors (152 males [65.2%]). The mean (SD) total accommodation score was 8.28 (3.79), and the median (IQR) score was 9.25 (5.00-12.00). No association was found between test accommodation score and the percentage of female or URM residents. However, for each 1-point increase in the test accommodation score, the relative risk that a resident was female was 1.05 (95% CI, 0.96-1.16), and the relative risk that an individual was a URM resident was 1.04 (95% CI, 1.00-1.07). An association was found between the percentage of female board members and the accommodation score: for each 10% increase in the percentage of board members who were female, the accommodation score increased by 1.20 points (95% CI, 0.23-2.16 points; P = .03). Conclusions and Relevance: This cross-sectional study found considerable variability in oral board examination accommodations among ACGME-accredited specialties, highlighting opportunities for improvement and standardization. Promoting diversity in leadership bodies may lead to greater accommodations for examinees in extenuating circumstances.

Biomechanical profile of varying suture button constructs in cadaveric specimens: a systematic review and meta-analysis.

Background: Suture button fixation of syndesmotic injuries allows for more physiologic motion of the ankle joint while maintaining adequate reduction and may avoid the need for additional surgeries, given the lower risk of syndesmotic diastasis and implant failure. Few studies have examined the optimal number and configuration of suture buttons for syndesmotic disruption. The purpose of this systematic review and meta-analysis is to compare different suture button configurations from the cadaveric literature and to assess their relative effect on the stability of the syndesmotic reduction and functional movement of the ankle. Methods: A literature search in the databases MEDLINE via PubMed, Embase via Elsevier, Scopus via Elsevier, and SPORTDiscus via EBSCO were searched through December 2022 to identify studies related to cadaveric modeling of the syndesmosis. Only cadaveric studies with suture button fixation and studies in English were included. The quality of cadaveric studies was assessed using the Quality Assessment for Cadaveric Studies (QUACS) tool. Revman 5.3 software was used to perform the meta-analysis. Results: The meta-analysis included 5 studies and 86 limbs. The systematic review included 15 studies. When comparing single and double suture button configurations, no difference was found between groups with regard to fibular rotation (MD =-0.9; 95% CI: -2.09 to 0.27; I2=79%; P=0.13) and both groups had similar rotational stability. The double suture button technique did demonstrate less sagittal fibular translation compared to the single suture button (MD =0.48; 95% CI: 0.02-0.94; I2=66%; P=0.04). When comparing two suture buttons in parallel and divergent configurations, studies did not find any differences with regard to strength or stability. Conclusions: There were no significant differences in biomechanical parameters when comparing single and double suture button constructs. While single button suture constructs result in minimal fibular rotation, double suture button constructs minimize fibular translation. This review may serve as a guide for clinicians when approaching these injuries.

Sociodemographic Trends in Telemedicine Visit Completion in Spine Patients During the COVID-19 Pandemic.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: This study identifies potential disparities in telemedicine utilization in the wake of the COVID-19 pandemic and its aftermath in patients receiving spine surgery. SUMMARY OF BACKGROUND DATA: COVID-19 led to the rapid uptake of telemedicine in the spine surgery patient population. While previous studies in other medical subspecialties have identified sociodemographic disparities in telemedicine uptake, this is the first study to identify disparities in patients undergoing spine surgery. MATERIALS AND METHODS: This study included patients who underwent spine surgery between June 12, 2018 and July 19, 2021. Patients were required to have at least one scheduled patient visit, either virtual (video or telephone visit) or in-person. Binary socioeconomic variables used for modeling included: urbanicity, age at the time of the procedure, sex, race, ethnicity, language, primary insurer, and patient portal utilization. Analyses were conducted for the entire cohort and separately for cohorts of patients who had visits scheduled within specific timeframes: Pre-COVID-19 surge, initial COVID-19 surge, and post-COVID-19 surge. RESULTS: After adjusting for all variables in our multivariable analysis, patients who utilized the patient portal had higher odds of completing a video visit compared with those who did not (OR: 5.21; 95% CI: 1.28, 21.23). Hispanic patients (OR: 0.44; 95% CI: 0.2, 0.98) or those living in rural areas (OR: 0.58; 95% CI: 0.36, 0.93) had lower odds of completing a telephone visit. Patients with no insurance or on public insurance had higher odds of completing a virtual visit of either type (OR: 1.88; 95% CI: 1.10, 3.23). CONCLUSION: This study demonstrates the disparity in telemedicine utilization across different populations within the surgical spine patient population. Surgeons may use this information to guide interventions aimed at reducing existing disparities and work with certain patient populations to find a solution.

Jones Fracture in the National Football League.

Background: Jones fracture, or proximal fifth metatarsal fracture, is a common injury in National Football League (NFL)-caliber athletes. Combine draft performance can greatly impact the long-term success of these athletes, and substantial emphasis has been placed on early return to play (RTP) and the minimization of post-operative complications after Jones fracture in these athletes. To date, no study has specifically described the treatment and outcomes of this injury specifically in NFL-caliber players, considering factors relevant to this unique population. Thus, the purpose of this review is to delve into Jones fracture in NFL-caliber athletes, evaluating the diagnostic, treatment, and RTP considerations. Methods: We searched Medline (PubMed), Embase (Elsevier), Scopus (Elsevier), and SPORTDiscus (EBSCOhost) for the concept of Jones fractures in the NFL. Using the PRISMA guidelines, a team of three reviewers conducted abstract screenings, full-text screenings, and the extraction of studies describing Jones fractures specifically in the NFL. Results: Of the 1911 studies identified, 6 primary retrospective studies met the inclusion and exclusion criteria. The heterogeneity of the outcome reporting precluded a meta-analysis; thus, a qualitative review of manuscripts describing Jones fracture was carried out. Classification, diagnosis, and treatment considerations, RTP statistics and outcomes, and complications were discussed. Amongst the primary studies, there were 285 Jones fractures, all athletes were able to RTP, and the average time to RTP ranged from 6 weeks to 27 weeks. For complications, with operative treatment, the refracture rate ranged from 4 to 12%, and incomplete healing ranged from 7 to 50%. RTP was 15 weeks for refractures. There were no patient-reported outcomes. Conclusions: The vast majority of Zone 2/3 Jones fractures are treated with IM screw fixation with or without adjunctive orthobiologics, such as bone marrow aspirate concentrate, in NFL-caliber athletes. The six major series investigating outcomes after the operative treatment of Jones fractures in NFL players reveal very positive findings overall with regard to RTP, reoperation, and career continuation.

Can tumor treating fields induce DNA damage and reduce cell motility in medulloblastoma cell lines?

OBJECTIVE: Medulloblastoma (MB) is the most common malignant pediatric brain tumor and accounts for approximately 20% of all pediatric CNS tumors. Current multimodal treatment is associated with a 70%-90% 5-year survival rate; however, the prognosis for patients with tumor dissemination and recurrent MB remains poor. The majority of survivors exhibit long-term neurocognitive complications; thus, more effective and less toxic treatments are critically needed. Tumor treating fields (TTFields) are low-intensity, alternating electric fields that disrupt cell division through physical interactions with key molecules during mitosis. Side effects from TTField therapy are minimal, making it an ideal candidate for MB treatment. METHODS: To determine if TTFields can be an effective treatment for MB, the authors conducted an in vitro study treating multiple MB cell lines. Three MB molecular subgroups (SHH [sonic hedgehog], group 3, and group 4) were treated for 24, 48, and 72 hours at 100, 200, 300, and 400 kHz. Combinatorial studies were conducted with the small-molecule casein kinase 2 inhibitor CX-4945. RESULTS: TTFields reduced MB cell growth with an optimal frequency of 300 kHz, and the most efficacious treatment time was 72 hours. Treatment with TTFields dysregulated actin polymerization and corresponded with a reduction in cell motility and invasion. TTFields also induced DNA damage (γH2AX, 53BP1) that correlated with an increase in apoptotic cells. The authors discovered that CX-4945 works synergistically with TTFields to reduce MB growth. In addition, combining CX-4945 and TTFields increased the cellular actin dysregulation, which correlated with a decrease in MB migration. CONCLUSIONS: The findings of this study demonstrate that TTFields may be a novel and less toxic method to treat patients with MB.

Outcomes With a Mobile Digital Health Platform for Patients Undergoing Spine Surgery: Retrospective Analysis.

BACKGROUND: Digital health solutions have been shown to enhance outcomes for individuals with chronic medical illnesses, but few have been validated for surgical patients. The digital health platform ManageMySurgery (MMS) has been validated for spine surgery as a feasible method for patients along their surgical journey through in-app education and completion of patient-reported outcomes surveys. OBJECTIVE: The aim of this study is to determine the rates of 90-day emergency room (ER) visits, readmissions, and complications in patients undergoing spine surgery using MMS compared to patients using traditional perioperative care alone. METHODS: Patients undergoing spine surgery at a US-based academic hospital were invited to use MMS perioperatively between December 2017 and September 2021. All patients received standard perioperative care and were classified as MMS users if they logged into the app. Demographic information and 90-day outcomes were acquired via electronic health record review. The odds ratios of having 90-day ER visits, readmissions, mild complications, and severe complications between the MMS and non-MMS groups were estimated using logistic regression models. RESULTS: A total of 1015 patients were invited, with 679 using MMS. MMS users and nonusers had similar demographics: the average ages were 57.9 (SD 12.5) years and 61.5 (SD 12.7) years, 54.1% (367/679) and 47.3% (159/336) were male, and 90.1% (612/679) and 88.7% (298/336) had commercial or Medicare insurance, respectively. Cervical fusions (559/1015, 55.07%) and single-approach lumbar fusions (231/1015, 22.76%) were the most common procedures for all patients. MMS users had a lower 90-day readmission rate (55/679, 8.1%) than did nonusers (30/336, 8.9%). Mild complications (MMS: 56/679, 8.3%; non-MMS: 32/336, 9.5%) and severe complications (MMS: 66/679, 9.7%; non-MMS: 43/336, 12.8%) were also lower in MMS users. MMS users had a lower 90-day ER visit rate (MMS: 62/679, 9.1%; non-MMS: 45/336, 13.4%). After adjustments were made for age and sex, the odds of having 90-day ER visits for MMS users were 32% lower than those for nonusers, but this difference was not statistically significant (odds ratio 0.68, 95% CI 0.45-1.02; P=.06). CONCLUSIONS: This is one of the first studies to show differences in acute outcomes for people undergoing spine surgery who use a digital health app. This study found a correlation between MMS use and fewer postsurgical ER visits in a large group of spine surgery patients. A planned randomized controlled trial will provide additional evidence of whether this digital health tool can be used as an intervention to improve patient outcomes.

Filtered Cerebrospinal Fluid From Patients With Amyotrophic Lateral Sclerosis Displays an Altered Proteome and Affects Motor Phenotype in a Mouse Model.

INTRODUCTION: Cerebrospinal fluid (CSF) has been implicated in amyotrophic lateral sclerosis (ALS) due to its ability to spread inflammatory proteins throughout the nervous system. We hypothesized that filtration of the CSF could remove pathogenic proteins and prevent them from altering motor phenotypes in a mouse model. METHODS: We filtered the CSF from 11 ALS patients via 100 kilodaltons (kD) molecular weight cut-off filters. We used mass spectrometry-based discovery proteomics workflows to compare protein abundances before and after filtration. To test the effects of CSF filtration on motor function, we injected groups of mice with saline, filtered ALS-CSF, or unfiltered ALS-CSF (n=12 per group) and assessed motor function via pole descent and open field tests. RESULTS: We identified proteins implicated in ALS pathogenesis and showed that these were removed in significant amounts in our workflow. Key filtered proteins included complement proteins, chitinases, serine protease inhibitors, and neuro-inflammatory proteins such as amyloid precursor protein, chromogranin A, and glial fibrillary acidic protein. Compared to the filtered ALS-CSF mice, unfiltered ALS-CSF mice took longer to descend a pole (10 days post-injection, 11.14 seconds vs 14.25 seconds, p = 0.02) and explored less on an open field (one day post-injection, 21.81 m vs 16.83 m, p = 0.0004). CONCLUSIONS: We demonstrated the ability to filter proteins from the CSF of ALS patients and identified potentially pathologic proteins that were reduced in quantity. Additionally, we demonstrated the ability of unfiltered ALS-CSF to induce motor deficits in mice on the pole descent and open field tests and showed that filtration could prevent this deficit. Given the lack of effective treatments for ALS, this could be a novel solution for patients suffering from this deadly and irreversible condition.

Correction: Casein kinase 2 inhibition sensitizes medulloblastoma to temozolomide.

The original version of this Article contained an error in the spelling of the author David Solow-Cordero, which was incorrectly given as David Solow-Codero. This has now been corrected in both the PDF and HTML versions of the Article.

Casein kinase 2 inhibition sensitizes medulloblastoma to temozolomide.

Medulloblastoma (MB) is the most common malignant pediatric brain tumor. Since surviving patients experience severe neurocognitive disabilities, better and more effective treatments are needed to enhance their quality of life. Casein kinase 2 (CK2) is known to regulate cell growth and survival in multiple cancers; however, the role of CK2 in MB is currently being studied. In this study, we verified the importance of CK2 in MB tumorigenesis and discovered that inhibition of CK2 using the small molecule inhibitor, CX-4945, can sensitize MB cells to a well-known and tolerated chemotherapeutic, temozolomide (TMZ). To study the role of CK2 in MB we modulated CK2 expression in multiple MB cells. Exogenous expression of CK2 enhanced cell growth and tumor growth in mice, while depletion or inhibition of CK2 expression decreased MB tumorigenesis. Treatment with CX-4945 reduced MB growth and increased apoptosis. We conducted a high-throughput screen where 4000 small molecule compounds were analyzed to identify compounds that increased the anti-tumorigenic properties of CX-4945. TMZ was found to work synergistically with CX-4945 to decrease cell survival and increase apoptosis in MB cells. O-6-methylguanine-DNA methyltransferase (MGMT) activity is directly correlated to TMZ sensitivity. We found that loss of CK2 activity reduced ß-catenin expression, a known MGMT regulator, which in turn led to a decrease in MGMT expression and an increased sensitivity to TMZ. Our findings show that CK2 is important for MB maintenance and that treatment with CX-4945 can sensitize MB cells to TMZ treatment.

Targeted genomic CRISPR-Cas9 screen identifies MAP4K4 as essential for glioblastoma invasion.

Among high-grade brain tumors, glioblastoma is particularly difficult to treat, in part due to its highly infiltrative nature which contributes to the malignant phenotype and high mortality in patients. In order to better understand the signaling pathways underlying glioblastoma invasion, we performed the first large-scale CRISPR-Cas9 loss of function screen specifically designed to identify genes that facilitate cell invasion. We tested 4,574 genes predicted to be involved in trafficking and motility. Using a transwell invasion assay, we discovered 33 genes essential for invasion. Of the 11 genes we selected for secondary testing using a wound healing assay, 6 demonstrated a significant decrease in migration. The strongest regulator of invasion was mitogen-activated protein kinase 4 (MAP4K4). Targeting of MAP4K4 with single guide RNAs or a MAP4K4 inhibitor reduced migration and invasion in vitro. This effect was consistent across three additional patient derived glioblastoma cell lines. Analysis of epithelial-mesenchymal transition markers in U138 cells with lack or inhibition of MAP4K4 demonstrated protein expression consistent with a non-invasive state. Importantly, MAP4K4 inhibition limited migration in a subset of human glioma organotypic slice cultures. Our results identify MAP4K4 as a novel potential therapeutic target to limit glioblastoma invasion.