Medicine, pharmacy and nursing trainees' perceptions of curriculum preparation to deprescribe and interprofessional roles in the deprescribing process.

With increasing rates of polypharmacy among older adults, preparedness of current and future health care professionals to identify and deprescribe potentially inappropriate medications (PIMs) is critical. Medicine (n = 28), pharmacy (n = 35) and nursing (n = 11) trainees enrolled in an interprofessional course completed a survey assessing preparedness, confidence and attitudes toward deprescribing, and perception of interprofessional roles in the process. Pharmacy (p = .001) and nursing (p = .007) felt that their curriculum prepared them better to identify and deprescribe PIMs compared to medicine trainees. Pharmacy trainees perceived significantly more barriers to deprescribing compared to medicine (p = .003), but not nursing trainees. Physicians and pharmacists were perceived as the main drivers of the deprescribing process. Current curricular content should be modified to address lack of preparedness to deprescribe in clinical practice. Addressing such gaps as part of an interprofessional team may increase interprofessional role recognition and translate into changes in clinical practice as trainees move into the workforce.

Evaluation of Endoscopic Iliopsoas Tenotomy for Treatment of Iliopsoas Impingement After Total Hip Arthroplasty.

BACKGROUND: Iliopsoas impingement after total hip arthroplasty (THA) occurs in up to 4.3% of patients resulting in functional groin pain. Operative treatment historically has included open iliopsoas tenotomy or acetabulum revision. We present a large single surgeon series of patients treated with endoscopic iliopsoas tenotomy for iliopsoas impingement after THA to evaluate the effectiveness and risks. METHODS: A consecutive series of 60 patients with iliopsoas impingement after THA treated with endoscopic iliopsoas tenotomy was retrospectively evaluated. Outcomes assessed were resolution of pain, change in Hip Outcome Score (HOS), and complications. Radiographs were reviewed by a musculoskeletal radiologist to evaluate component positioning and to compare with a control cohort. RESULTS: At last follow-up (mean 5.5 months), 93.3% of patients had resolution of pain. The HOS activities of daily living (ADL) subscale mean was 57.5 (range 10.9-89.3, standard deviation [SD] 18.8) preoperatively and 71.6 (range 14.1-100, SD 26.1) postoperatively (P = .005). The HOS sports subscale mean was 37.3 (range 0-83.3, SD 24.0) preoperatively and 58.1 (range 0-100, SD 33.2) postoperatively (P = .002). One complication was reported, a postoperative hematoma managed conservatively. Body mass index and increased offset were associated with iliopsoas symptoms after THA in this series. CONCLUSION: Endoscopic iliopsoas tenotomy after THA had a 93.3% resolution of pain, clinically important improvements in HOS, and low rate of complications. Endoscopic tenotomy should be considered as a treatment option in patients with iliopsoas impingement after THA.

A descriptive qualitative examination of knowledge translation practice among health researchers in Manitoba, Canada.

BACKGROUND: The importance of effective translation of health research findings into action has been well recognized, but there is evidence to suggest that the practice of knowledge translation (KT) among health researchers is still evolving. Compared to research user stakeholders, researchers (knowledge producers) have been under-studied in this context. The goals of this study were to understand the experiences of health researchers in practicing KT in Manitoba, Canada, and identify their support needs to sustain and increase their participation in KT. METHODS: Qualitative semi-structured interviews were conducted with 26 researchers studying in biomedical; clinical; health systems and services; and social, cultural, environmental and population health research. Interview questions were open-ended and probed participants' understanding of KT, their experiences in practicing KT, barriers and facilitators to practicing KT, and their needs for KT practice support. RESULTS: KT was broadly conceptualized across participants. Participants described a range of KT practice experiences, most of which related to dissemination. Participants also expressed a number of negative emotions associated with the practice of KT. Many individual, logistical, and systemic or organizational barriers to practicing KT were identified, which included a lack of institutional support for KT in both academic and non-academic systems. Participants described the presence of good relationships with stakeholders as a critical facilitator for practicing KT. The most commonly identified needs for supporting KT practice were access to education and training, and access to resources to increase awareness and promotion of KT. While there were few major variations in response trends across most areas of health research, the responses of biomedical researchers suggested a unique KT context, reflected by distinct conceptualizations of KT (such as commercialization as a core component), experiences (including frustration and lack of support), and barriers to practicing KT (for example, intellectual property concerns). CONCLUSIONS: The major findings of this study were the continued variations in conceptualization of KT, and persisting support needs that span basic individual to comprehensive systemic change. Expanding the study to additional regions of Canada will present opportunities to compare and contrast the state of KT practice and its influencing factors.

Teaching Through Interactions in Secondary School Classrooms: Revisiting the Factor Structure and Practical Application of the Classroom Assessment Scoring System-Secondary.

Valid measurement of how students' experiences in secondary school classrooms lead to gains in learning requires a developmental approach to conceptualizing classroom processes. This article presents a potentially useful theoretical model, the Teaching Through Interactions framework, which posits teacher-student interactions as a central driver for student learning and that teacher-student interactions can be organized into three major domains. Results from 1,482 classrooms provide evidence for distinct emotional, organizational, and instructional domains of teacher-student interaction. It also appears that a three-factor structure is a better fit to observational data than alternative one- and two-domain models of teacher-student classroom interactions, and that the three-domain structure is generalizable from 6th through 12th grade. Implications for practitioners, stakeholders, and researchers are discussed.

A mixed-methods assessment of community-engaged learning in a Master of Public Health program.

Objective: Community-engaged learning is used in Master of Public Health programs to enhance student training, connect with communities, help solve societal issues, develop competencies, and build partnerships. However, it is unclear how much community-engaged learning components supplement existing Master of Public Health programs and prepare students in developing these competencies. Thus, the aim of this study was to apply an explanatory mixed-methods study design to evaluate a Canadian Master of Public Health program's community-engaged learning activities and propose recommendations to strengthen public health training and course delivery. Methods: We conducted a questionnaire among Master of Public Health students (n = 25), focus group discussion with a subset of these students (n = 7), and one-on-one semi-structured telephone interviews with community partners who had previously hosted Master of Public Health students for practicum placements (n = 11). Results: Community-engagement enhanced learning among Master of Public Health students, with the practicum placement, and program development capstone resulting in the largest self-reported development. Students in the focus group indicated community engagement provided skill and professional development, but also identified wanting additional curriculum coverage on various statistical software and qualitative research methods. Interviews with community partners revealed benefits of practicum placements such as mutual knowledge transfer, increased organizational capacity, and strengthened academic-community partnerships. Community partners also commented on challenges with recruitment, training, and aligning student-organization goals. Conclusion: The findings from this study suggest that an update to the Master of Public Health program curriculum, its core competencies, a combination of community-engagement activities, and future evaluations will be needed to advance education delivery.

The successful implementation of the Navio robotic technology required 29 cases.

Robotic-assisted total knee arthroplasty (RA-TKA) has potential benefits of improved restoration of mechanical alignment, accuracy of bony resection, and balancing. The purpose of this study was to determine the number of cases necessary for a single surgeon to achieve a constant, steady-state surgical time. The secondary purpose was to identify which steps demonstrated the most time reduced. This was a prospective study assessing intraoperative time for 60 RA-TKA with the Navio surgical system. Overall arthroplasty time and duration for each step were recorded. Statistical analysis included a nonlinear regression and survival regression. Successful implementation required 29 cases to achieve a steady-state. The average time decreased from 41.8 min for the first cohort to 31.1 min for the last cohort, a 26% decrease. The step with the greatest reduction was the "Review of Intraoperative Plan" with a reduction of 2.1 min. This study demonstrates surgical times averaging below 60 min and a learning curve that is complete in 29 cases with the surgeon reporting a high level of confidence with the system at 10 cases. Though Navio assisted TKA showed a significantly slower operative time, we are hopeful that future generations of robotic technology will be more efficiently implemented by surgeons.

Discrepancies in Work-Family Integration Between Female and Male Orthopaedic Surgeons.

BACKGROUND: Female surgeons, representing 6.5% of the American Academy of Orthopaedic Surgeons, are particularly vulnerable to work-family conflict. This conflict may deter women from considering orthopaedic surgery as a specialty. The study objective was to identify differences in work-family integration between female and male orthopaedic surgeons in the United States. METHODS: An anonymous survey collecting data within the domains of work, family, and satisfaction was completed by 347 orthopaedic surgeons (153 female, 194 male). Differences in responses between males and females were identified. RESULTS: Female surgeons were younger than males (mean, 41.1 versus 50.1 years; p < 0.001) and earlier in their careers, with 60.3% of males in practice >10 years compared with 26.1% of females (p < 0.001). Consulting (7.8% versus 31.4%; p < 0.001), course faculty positions (19.0% versus 39.2%; p < 0.001), and academic and leadership titles (30.7% versus 47.4%; p = 0.002) were significantly less common among females. There was a significant income disparity between females (mean yearly income, $300,000 to $400,000) and males (mean, $400,000 to $500,000; p < 0.001). Females were more likely to have never married (12.4% versus 2.6%; p < 0.001), or they married at a later mean age (30.2 ± 4.7 versus 28.3 ± 3.9 years; p < 0.001). Females were more likely to have no children (29.4% versus 7.8%; p < 0.001), require fertility treatment (32.0% versus 11.9%; p < 0.001), and not have children until after completing their medical training (63.0% versus 31.1%; p < 0.001). Female surgeons reported more responsibility in parenting (p < 0.001) and household duties (p < 0.001) than males. Work-family balance satisfaction was 72.3% in females and 82.1% in males (p = 0.081). CONCLUSIONS: This study highlights deficiencies in work-family integration that appear to uniquely impact female orthopaedic surgeons. Female surgeons delay starting a family, more frequently require fertility treatments, carry more responsibility at home, have fewer academic and leadership roles, earn lower incomes, and are less satisfied with work-family balance relative to males. The discrepancy in work-family integration must be addressed to attract, support, and retain women as successful orthopaedic surgeons.

Predictors of Successful Early Discharge for Total Hip and Knee Arthroplasty in Octogenarians.

Background: Decreased length of stay after total joint arthroplasty (TJA) is becoming a more common way to contain healthcare costs and increase patient satisfaction. There is little evidence to support "early" discharge in elderly patients. Purpose: We sought to identify preoperative factors that correlated with early discharge (by postoperative day [POD] 1) in comparison to late discharge (after POD2) in octogenarians after TJA. Methods: In a retrospective cohort study from a single institution, we identified 482 patients ages 80 to 89 who underwent primary TJA from January 2014 to December 2017; 319 had total knee arthroplasty (TKA) and 163 had total hip arthroplasty (THA). Data collected included preoperative knee range of motion (ROM), demographics, and comorbidities; 90-day readmission and mortality rates were also evaluated. P values for continuous data were calculated using student's t test and for categorical data using χ2 testing. Results: Of octogenarian patients, 30.9% were discharged by POD1. Early discharge was associated with being male, married, and nonsmoking, as well as having an American Society of Anesthesiologists (ASA) score of 2, independent preoperative ambulation, and a postoperative caregiver. Type of procedure (TKA vs THA), body mass index, laterality, preoperative range of motion (ROM) for TKA, and single vs multilevel home did not affect the probability of early discharge. Discharge on POD1 was not associated with increased 90-day readmission rates. There were no deaths. Conclusion: Early discharge for octogenarians can be successfully implemented in a select subset of patients without increasing 90-day readmission or death rates. There are multiple factors that predict successful early discharge.

Clinical evaluation of direct anterior approach total hip arthroplasty for severe developmental dysplasia of the hip.

It is challenging to treat developmental dysplasia of the hip (DDH) classified Crowe III-IV using direct anterior approach (DAA) total hip arthroplasty (THA), and very little is known on its outcome. This study aimed to investigate the clinical result in this defined disorder with DAA versus posterolateral approach. Twenty-three consecutive hips with Crowe III-IV DDH who underwent DAA were retrospectively evaluated from 2016 through 2018. Outcomes were primarily assessed by HHS, WOMAC, and SF-12 physical scales. The second evaluations included leg length discrepancy, hip muscle strength, radiographic review, complications, and limp recovery. Results were compared to a control cohort of 50 hips underwent posterolateral THA concurrently within the observational period. At last follow-up (DAA 28.5 months; PLA 39.0 months), the mean increase of the HHS for DAA was 48.2 and 30.3 for PLA (p = 0.003). The improvement in WOMAC score in DAA cohort was 15.89 higher that of the PLA cohort after adjusting preoperative difference [R2 = 0.532, P = 0.000, 95% CI (10.037, 21.735)]. DAA had more rapid recovery of hip abductor strength at 1-month (p = 0.03) and hip flexor strength at 3 months (p = 0.007) compared to PLA. No significant differences were found in the radiographic analysis with the exception of increased acetabular anteversion in the DAA cohort (p = 0.036). Satisfactory improvement in limp, indicated by the percentage of limp graded as none and mild to the total, was much higher in DAA cohort (97.6%), compared to that of PLA cohort (90.0%, p = 0.032). DAA for high-dislocated dysplasia demonstrate a significant improvement in clinical result comparable to posterolateral approach. Improved clinical outcome in terms of increased HHS and WOMAC scores, rapid recovery of hip abductor and flexor strength, and enhanced limp recovery without an increased risk in complications, could be acquired when the surgeons were specialized in this approach.

Danielson's Framework for Teaching: Convergence and Divergence With Conceptions of Effectiveness in Special Education.

Danielson's Framework for Teaching (FFT) is currently used in more than 20 states to inform teacher evaluation and professional learning. To investigate whether FFT promotes instruction that appropriately responds to the needs of students with learning disabilities, we conduct a systematic content analysis of the instructional approach emphasized in the FFT's Instructional Domain (Domain 3) of Danielson's FFT. We frame our study using cognitive load theory and research regarding effective instruction for students with disabilities. We end by discussing implications regarding the evaluation and development of effective teaching for students with learning disabilities.

Direct anterior approach total hip arthroplasty for Crowe III and IV dysplasia.

High-dislocated hip dysplasia is challenging to treat with total hip arthroplasty via the direct anterior approach (DAA). The DAA has potential advantages including optimizing component positioning, enhanced hip stability, and a more rapid postoperative recovery. We present a surgical technique for DAA total hip arthroplasty for hip dysplasia that includes preoperative planning, soft tissue releases, subtrochanteric osteotomy, component placement, and intraoperative nerve monitoring and imaging. This technique provides detailed technical instructions, specifically including pearls and pitfalls, and complication prevention strategies.

Surgical Simulation Maximizing the Use of Fresh-Frozen Cadaveric Specimens: Examination of Tissue Integrity Using Ultrasound.

BACKGROUND: Arthroscopic surgical simulation, including the use of cadaveric tissue, is valuable for training orthopedic surgery residents. However, it is unclear how often fresh-frozen cadaveric tissue can be reused to provide a reproducible model for developing arthroscopic skills. OBJECTIVE: We determined the usefulness of ultrasound in evaluating tissue degradation in fresh-frozen shoulder and knee joints used for surgical simulation. METHODS: Between February 7 and April 11, 2017, orthopedic residents participated in 6 wet lab sessions during 1 rotation. Knee and shoulder specimens were subjected to ultrasound using a SonoSite Edge machine and a linear probe after each freeze-and-thaw cycle. Degradation of each structure was determined based on standards created for living tissue and comparisons to previous images of the same tissue before initial use. RESULTS: Ultrasonographic assessment of the 2 knee and 2 shoulder specimens revealed lost integrity in subcutaneous fat and muscle with evidence of increased hypoechoicity and loss of normal fiber orientation and density in all specimens examined. Tendons, ligaments, cartilage, iliotibial band, and bone did not lose integrity during freezing and thawing. Ultrasonographic assessment revealed no loss of joint structure integrity. However, the intra-articular work assigned for the simulation curriculum had been carried out to a degree that by the third use, little opportunity remained for further arthroscopic practice on that specimen. CONCLUSIONS: In this study, ultrasound findings showed that fresh-frozen shoulder and knee specimens maintained structural integrity useful for simulation training after 3 cycles of freezing.

Hip Arthrography Complicated by Air Embolism in Infants: A Report of 2 Cases.

CASE: We report 2 cases of infants with developmental dysplasia of the hip who underwent arthrography of the hip with use of air for structure identification, which resulted in a presumed air embolism and deep oxygen desaturation. This led to the hypothesis that there is an increased potential of air embolism in the pediatric population given the vascular anatomy of the hip. CONCLUSION: These 2 cases document the important and not well-known complication of air embolism during air arthrography, which resulted in a change of practice for the authors. We strongly recommend against the use of air as an adjunct to routine arthrography in children.

Hip Arthroscopy Complicated by a Deep Vein Thrombosis in a Patient with May-Thurner Syndrome: A Case Report.

CASE: A 20-year-old woman underwent hip arthroscopy with a labral repair, a femoral neck osteoplasty, and acetabular rim trimming. Six weeks after surgery, she presented with leg pain and edema, and was found to have an extensive deep vein thrombosis (DVT). Additional imaging studies revealed apparent extrinsic compression of the left common iliac vein, a vascular anatomic variant consistent with May-Thurner syndrome (MTS). CONCLUSION: Thromboembolic events in patients undergoing low-risk procedures should raise concern for additional risk factors, including MTS. Identifying this variant in patients is important to prevent future thrombotic complications.

Using Linkage Maps as a Tool To Determine Patterns of Chromosome Synteny in the Genus Salvelinus.

Next generation sequencing techniques have revolutionized the collection of genome and transcriptome data from nonmodel organisms. This manuscript details the application of restriction site-associated DNA sequencing (RADseq) to generate a marker-dense genetic map for Brook Trout (Salvelinus fontinalis). The consensus map was constructed from three full-sib families totaling 176 F1 individuals. The map consisted of 42 linkage groups with a total female map size of 2502.5 cM, and a total male map size of 1863.8 cM. Synteny was confirmed with Atlantic Salmon for 38 linkage groups, with Rainbow Trout for 37 linkage groups, Arctic Char for 36 linkage groups, and with a previously published Brook Trout linkage map for 39 linkage groups. Comparative mapping confirmed the presence of 8 metacentric and 34 acrocentric chromosomes in Brook Trout. Six metacentric chromosomes seem to be conserved with Arctic Char suggesting there have been at least two species-specific fusion and fission events within the genus Salvelinus In addition, the sex marker (sdY; sexually dimorphic on the Y chromosome) was mapped to Brook Trout BC35, which is homologous with Atlantic Salmon Ssa09qa, Rainbow Trout Omy25, and Arctic Char AC04q. Ultimately, this linkage map will be a useful resource for studies on the genome organization of Salvelinus, and facilitates comparisons of the Salvelinus genome with Salmo and Oncorhynchus.

A scoring system to predict postoperative medical complications in high-risk patients undergoing elective thoracic and lumbar arthrodesis.

BACKGROUND CONTEXT: Various surgical factors affect the incidence of postoperative medical complications following elective spinal arthrodesis. Because of the inter-relatedness of these factors, it is difficult for clinicians to accurately risk-stratify individual patients. PURPOSE: Our goal was to develop a scoring system that predicts the rate of major medical complications in patients with significant preoperative medical comorbidities, as a function of the four perioperative parameters that are most closely associated with the invasiveness of the surgical intervention. STUDY DESIGN/SETTING: This study used level 2, Prognostic Retrospective Study. PATIENT SAMPLE: The patient sample consisted of 281 patients with American Society of Anesthesiologists (ASA) scores of 3-4 who underwent elective thoracic, lumbar, or thoracolumbar fusion surgeries from 2007 to 2011. OUTCOME MEASURES: Physiologic risk factors, number of levels fused, complications, operative time, intraoperative fluids, and estimate blood loss were the outcome measures of this study. METHODS: Risk factors were recorded, and patients who suffered major medical complications within the 30-day postoperative period were identified. We used chi-square tests to identify factors that affect the medical complication rate. These factors were ranked and scored by quartiles. The quartile scores were combined to form a single composite score. We determined the major medical complication rate for each composite score, and divided the cohort into quartiles again based on score. A Pearson linear regression analysis was used to compare the incidence of complications to the score. RESULTS: The number of fused levels, operative time, volume of intraoperative fluids, and estimated blood loss influenced the complication rate of patients with ASA scores of 3-4. The quartile ranking of each of the four predictive factors was added, and the sum became the composite score. This score predicted the complication rate in a linear fashion ranging from 7.6% for the lowest risk group to 34.7% for the highest group (r=0.998, p<.001). CONCLUSIONS: Taken together, the four factors, though not independent of one another, proved to be strongly predictive of the major medical complication rate. This score can be used to guide medical management of thoracic and lumbar spinal arthrodesis patients with preexisting medical comorbidities.

HIV controllers are distinguished by chemokine expression profile and HIV-specific T-cell proliferative potential.

BACKGROUND: HIV controllers demonstrate a natural ability to control HIV replication in the absence of antiretroviral therapy. We performed a comprehensive evaluation of inflammation and T-cell activation in a demographically unique cohort of HIV controllers and noncontrollers. METHODS: Plasma concentrations of 22 cytokines and chemokines were evaluated using a multiplex bead array approach. Multicolor flow cytometry was used to measure baseline levels of T-cell activation and regulatory T cells (Tregs) and HIV-specific T-cell cytokine (interferon γ, interleukin 2) and proliferation responses. RESULTS: HIV controllers were characterized by elevated macrophage inflammatory protein 1α and low levels of interferon γ-induced protein 10, monocyte chemotactic protein 1, and Transforming growth factor beta. Activated (CD38(+) HLA DR(+)) CD4(+) and CD8(+) T cells were reduced in HIV controllers relative to noncontrollers. HIV controllers and noncontrollers had comparable proportions of Tregs within the CD4(+) T-cell compartment, but absolute Treg counts were depleted in noncontrollers. Absolute Treg counts correlated inversely with T-cell activation. Proliferative CD4(+) and CD8(+) T-cell responses directed against HIV gag epitopes were found most frequently among HIV controllers with the lowest viral loads (elite controllers) and were rarely detected among noncontrollers, supporting a relationship between HIV-specific T-cell proliferation and viral control. CONCLUSIONS: Collectively, these data suggest a model in which HIV controllers maintain low levels of viral replication through robust HIV-specific T-cell responses in an environment of low inflammation and reduced availability of activated target cells.

iSTART 2: improvements for efficiency and effectiveness.

iSTART (interactive strategy training for active reading and thinking) is a Web-based reading strategy trainer that develops students' ability to self-explain difficult text as a means to improving reading comprehension. Its curriculum consists of modules presented interactively by pedagogical agents: an introduction to the basics of using reading strategies in the context of self-explanation, a demonstration of self-explanation, and a practice module in which the trainee generates self-explanations with feedback on the quality of reading strategies contained in the self-explanations. We discuss the objectives that guided the development of the second version of iSTART toward the goals of increased efficiency for the experimenters and effectiveness in the training. The more pedagogically challenging high school audience is accommodated by (1) a new introduction that increases interactivity, (2) a new demonstration with more and better focused scaffolding, and (3) a new practice module that provides improved feedback and includes a less intense but more extended regimen. Version 2 also benefits experimenters, who can set up and evaluate experiments with less time and effort, because pre- and posttesting has been fully computerized and the process of preparing a text for the practice module has been reduced from more than 1 person-week to about an hour's time.