Surgeon variation in rates of surgery for trapeziometacarpal osteoarthritis in the United States.

We identified wide variation in surgery for trapeziometacarpal osteoarthritis among surgeons in the United States, with 42% performing no surgery, a median rate of surgery of 1.9/year, and 2% performed more than 30 procedures annually, representing 15% of all surgical procedures for TMC arthritis.

Parsing the toxicity paradox: Composition and duration of exposure alter predicted oil spill effects by orders of magnitude.

Oil spilled into an aquatic environment produces oil droplet and dissolved component concentrations and compositions that are highly variable in space and time. Toxic effects on aquatic biota vary with sensitivity of the organism, concentration, composition, environmental conditions, and frequency and duration of exposure to the mixture of oil-derived dissolved compounds. For a range of spill (surface, subsea, blowout) and oil types under different environmental conditions, modeling of oil transport, fate, and organism behavior was used to quantify expected exposures over time for planktonic, motile, and stationary organisms. Different toxicity models were applied to these exposure time histories to characterize the influential roles of composition, concentration, and duration of exposure on aquatic toxicity. Misrepresenting these roles and exposures can affect results by orders of magnitude. Well-characterized laboratory studies for <24-hour exposures are needed to improve toxicity predictions of the typically short-term exposures that characterize spills.

AOA Critical Issues: A Culture of Safety Across All Orthopaedic Professional Endeavors.

ABSTRACT: Medical professionals strive for a culture of safety in which error is anticipated, systems are designed to catch an error before it causes harm, and each event is an opportunity for specific clinicians and the system they work in to improve. A culture of safety is based on behavioral ethics, which recognizes that the automatic functions of the human mind can lead good people to misstep, and it incorporates tools such as checklists that embody critical thinking in order to help limit missteps and associated harm. Although the discussion surrounding a culture of safety often focuses on patient care, the social contract between physicians and society involves expectations that physicians will use their expertise to promote the public good in all of their professional endeavors. For example, lapses in professional conduct in the management of conflicts of interest and in ethical marketing have led to restrictions in physician self-regulation. Orthopaedic surgeons can cultivate a culture of safety and a growth mindset across all aspects of the profession, including media coverage of musculoskeletal illness, surgeon participation in informational media (e.g., podcasts and blogs), the marketing of oneself or one's practice, practice patterns and variations, academic discourse, expert legal testimony, the development and implementation of policy and law, and commercial ventures. Systems that anticipate the human potential for missteps; create tools, tactics, and structures to limit missteps and associated harm; and support surgeons and their teams in all professional endeavors can contribute to the effective and fulfilling promotion of the public good.

Surgeon Implicit Association of Women With Supportive Roles in Medicine.

BACKGROUND: In a previous study, we documented patient implicit bias that surgeons are men. As a next step, we tested the implicit bias of surgeons that women in medicine have leading (chair, surgeon) or supporting roles (medical assistant, physician assistant). QUESTIONS/PURPOSE: (1) What is the relationship between the implicit associations and expressed beliefs of surgeons regarding women as leaders in medicine? (2) Are there factors associated with surgeon implicit association and explicit preference regarding the roles of women in medicine? METHODS: A total of 102 musculoskeletal surgeon members of the Science of Variation Group (88 men and 12 women) completed an implicit association test (IAT) of implicit bias regarding sex and lead/support roles in medicine and a questionnaire that addressed respondent demographics and explicit preference regarding women's roles. The IAT consisted of seven rounds with five rounds used for teaching and two rounds for evaluation. RESULTS: On average, there was an implicit association of women with supportive roles (D-score: -48; SD 4.7; P < 0.001). The mean explicit preference was for women in leadership roles (median: 73; interquartile ranges: 23 to 128; P < 0.001). There was a correlation between greater explicit preference for women in a leading role and greater implicit bias toward women in a supporting role (ρ = 0.40; P < 0.001). Women surgeons and shoulder and elbow specialists had less implicit bias that women have supporting roles. CONCLUSION: The observation that musculoskeletal surgeons have an explicit preference for women in leading roles in medicine but an implicit bias that they have supporting roles-more so among men surgeons-documents the gap between expressed opinions and ingrained mental processing that is the legacy of the traditional "roles" of women in medicine and surgery. To resolve this gap, we will need to be intentional about promotion of and emersion in experiences where the leader is a woman. LEVEL OF EVIDENCE: III.

Protocol of a Multicenter Prospective Trial of Office-Based Carpal Tunnel Release With Ultrasound Guidance (ROBUST).

Background Carpal tunnel release (CTR) is a common surgical procedure for patients with severe or refractory carpal tunnel syndrome (CTS) symptoms. Historically, CTR procedures have been performed in a hospital or an ambulatory surgery center (ASC). However, due to advancements in techniques, greater patient demand, and concerns about growing healthcare costs, there is a distinct trend toward performing CTR procedures in an office-based setting. Several small studies with limited follow-up duration have demonstrated the feasibility of CTR with ultrasound guidance (CTR-US) when performed in an office-based setting. The objective of this study is to evaluate the safety and effectiveness of office-based CTR-US in a large cohort of patients (n=140) with symptomatic CTS followed for two years post-treatment. Design and methods ROBUST is a prospective multicenter observational study in which 140 subjects at up to 12 sites in the United States will be treated with CTR-US in an office-based setting. The primary endpoint of the study is the change in the Boston Carpal Tunnel Questionnaire Symptom Severity Scale score. Secondary endpoints include time to return to normal daily activities, time to return to work among employed subjects, change in the Boston Carpal Tunnel Questionnaire Functional Status Scale score, change in the Michigan Hand Questionnaire overall and domain scores, change in the Numeric Pain Scale score, change in the EuroQoL-5 Dimension 5-Level score, global satisfaction scores, and the incidence of device or procedure-related adverse events. The primary analysis of study endpoints will occur three months post-treatment. Patient follow-up in this study will continue for two years. Conclusions A central institutional review board approved the study protocol, and a data safety monitoring board will provide study oversight. The authors plan to report study results at medical conferences and in peer-reviewed medical journals. The outcomes of ROBUST will provide physicians, patients, and payors with important safety and effectiveness data regarding the clinical utility of CTR-US when performed in an office setting.

Recommendations for improving the reporting and communication of aquatic toxicity studies for oil spill planning, response, and environmental assessment.

Standardized oil toxicity testing is important to ensure comparability of study results, and to generate information to support oil spill planning, response, and environmental assessments. Outcomes from toxicity tests are useful in the development, improvement and validation of effects models, and new or revised knowledge could be integrated into existing databases and related tools. To foster transparency, facilitate repeatability and maximize use and impact, outcomes from toxicity tests need to be clearly reported and communicated. This work is part of a series of reviews to support the modernization of the "Chemical Response to Oil Spills: Ecological Effects Research Forum" protocols focusing on technological advances and best toxicity testing practices. Thus, the primary motivation of the present work is to provide guidance and encourage detailed documentation of aquatic toxicity studies. Specific recommendations are provided regarding key reporting elements (i.e., experimental design, test substance and properties, test species and response endpoints, media preparation, exposure conditions, chemical characterization, reporting metric corresponding to the response endpoint, data quality standards, and statistical methods, and raw data), which along with a proposed checklist can be used to assess the completeness of reporting elements or to guide study conduct. When preparing journal publications, authors are encouraged to take advantage of the Supplementary Material section to enhance dissemination and access to key data and information that can be used by multiple end-users, including decision-makers, scientific support staff and modelers. Improving reporting, science communication, and access to critical information enable users to assess the reliability and relevance of study outcomes and increase incorporation of results gleaned from toxicity testing into tools and applications that support oil spill response decisions. Furthermore, improved reporting could be beneficial for audiences outside the oil spill response community, including peer reviewers, journal editors, aquatic toxicologists, researchers in other disciplines, and the public.

Optimizing Outcomes By Optimizing Bone Health.

Orthopaedic surgeons have long been aware of the importance of metabolic bone health for fracture healing; however, recent attention has focused on optimization of bone health before elective surgery and also regarding pathways to ensure patients have appropriate evaluation and treatment for bone health issues. It is important to describe issues of importance to fragility fracture care and prevention and optimization of outcomes before elective or fracture surgery. To address the challenge of who has the time, expertise, and appropriate patient contact to identify and treat patients at risk of bone metabolic issues, one model for a suggested pathway to ensure these patients are identified and treated is outlined.

Nerve Conditions of the Upper Limb: How Not to Miss or Mismanage.

There are several issues associated with nerve compression syndromes of the upper limb; ultrasonography is a useful diagnostic tool. The orthopaedic surgeon should know how to evaluate and treat patients who do not obtain expected relief following carpal or cubital tunnel release, and also be knowledgeable about the workup and evaluation of patients with conditions of debatable pathology and treatment, such as radial tunnel syndrome or pronator syndrome. Recent studies on suprascapular neuropathy include discussions about the pathophysiology and etiology of the condition, its natural history, and who might benefit from surgery.

Surgical management of osteoarthritis in the shoulder and elbow.

Interesting recent trends are apparent in the setting of shoulder and elbow pathology. There is an increase in utilization of shoulder arthroplasty for osteoarthritis and post traumatic arthritis. At the same time, there remain limited options for osteoarthritis of the elbow particularly in the young and or active patient. This manuscript details surgical options for osteoarthritis at the elbow and shoulder.

COVID-19 prompts rapid and safe transition of chemotherapy into homes.

With the identification of the COVID-19 pandemic in early 2020, cancer-based clinical services in South Australia moved quickly to protect patients on active anti-cancer treatment who are particularly vulnerable to infective complications. This took the form of shifting 600 chemotherapy visits into the patients' homes via expansion of an existing arrangement between a public hospital network and an established private home chemotherapy service. Despite calls for caution from some oncology organisations and a relative paucity in specific clinical data supporting this approach, it proved to be a safe and efficient transition with additional unexpected benefits.

The Use and Effectiveness of an Online Diagnostic Support System for Blood Film Interpretation: Comparative Observational Study.

BACKGROUND: The recognition and interpretation of abnormal blood cell morphology is often the first step in diagnosing underlying serious systemic illness or leukemia. Supporting the staff who interpret blood film morphology is therefore essential for a safe laboratory service. This paper describes an open-access, web-based decision support tool, developed by the authors to support morphological diagnosis, arising from earlier studies identifying mechanisms of error in blood film reporting. The effectiveness of this intervention was assessed using the unique resource offered by the online digital morphology Continuing Professional Development scheme (DM scheme) offered by the UK National External Quality Assessment Service for Haematology, with more than 3000 registered users. This allowed the effectiveness of decision support to be tested within a defined user group, each of whom viewed and interpreted the morphology of identical digital blood films. OBJECTIVE: The primary objective of the study was to test the effectiveness of the decision support system in supporting users to identify and interpret abnormal morphological features. The secondary objective was to determine the pattern and frequency of use of the system for different case types, and to determine how users perceived the support in terms of their confidence in decision-making. METHODS: This was a comparative study of identical blood films evaluated either with or without decision support. Selected earlier cases from the DM scheme were rereleased as new cases but with decision support made available; this allowed a comparison of data sets for identical cases with or without decision support. To address the primary objectives, the study used quantitative evaluation and statistical comparisons of the identification and interpretation of morphological features between the two different case releases. To address the secondary objective, the use of decision support was assessed using web analytical tools, while a questionnaire was used to assess user perceptions of the system. RESULTS: Cases evaluated with the aid of decision support had significantly improved accuracy of identification for relevant morphological features (mean improvement 9.8%) and the interpretation of those features (mean improvement 11%). The improvement was particularly significant for cases with higher complexity or for rarer diagnoses. Analysis of website usage demonstrated a high frequency of access for web pages relevant to each case (mean 9298 for each case, range 2661-24,276). Users reported that the decision support website increased their confidence for feature identification (4.8/5) and interpretation (4.3/5), both within the context of training (4.6/5) and also in their wider laboratory practice (4.4/5). CONCLUSIONS: The findings of this study demonstrate that directed online decision support for blood morphology evaluation improves accuracy and confidence in the context of educational evaluation of digital films, with effectiveness potentially extending to wider laboratory use.

The bioavailability of oil droplets trapped in river gravel by hyporheic flows.

Little is known about the fate of oil spills in rivers. Hyporheic flows of water through river sediments exchange surface and groundwater and create upwelling and downwelling zones that are important for fish spawning and embryo development. Risk assessments of oil spills to rivers do not consider the potential for hyporheic flows to carry oil droplets into sediments and the potential for prolonged exposure of fish to trapped oil. This project assessed whether oil droplets in water flowing through gravel will be trapped and whether hydrocarbons partitioning from trapped oil droplets are bioavailable to fish. Columns packed with gravel were injected with oil-in-water dispersions prepared with light crude, medium crude, diluted bitumens, and heavy fuel oil to generate a series of oil droplet loadings. The concentrations of oil trapped in the gravel increased with oil loading and viscosity. When the columns were perfused with clean water, oil concentrations in column effluents decreased to the detection limit within the first week of water flow, with sporadically higher concentrations associated with oil droplet release. Despite the low concentrations of hydrocarbons measured in column effluent, hydrocarbons were bioavailable to juvenile rainbow trout (Oncorhynchus mykiss) for more than three weeks of water flow, as indicated by strong induction of liver ethoxyresorufin-o-deethylase activity. These findings indicate that ecological risk assessments and spill response should identify and protect areas in rivers sensitive to contaminant trapping.

Ethics and Professionalism: The Role of Self-Regulation and Peer Review in Maintaining Hand Surgery's Standards.

The practice of hand surgery is bound by the need for each of us to maintain our profession's high standards by fulfilling our peers' and society's expectations regarding ethical and professional behavior. Our profession is self-regulated by local, state, and national organizations, which provide expectations and standards for practice. This manuscript reviews the resources available from such organizations to foster standards of practice.

Editorial Commentary: Elbow Arthroscopy Is a Safe Procedure. Sure.

Elbow arthroscopy is a procedure that is of great potential use and yet also of grave potential risks. To balance the risk-versus-reward consideration, one must be aware of the potential complications associated with this procedure, weigh them against the potential advantages, and understand one's own skills and familiarity with the procedure. There is no doubt that elbow arthroscopy has changed and even revolutionized our management of pathology about the elbow; however, one must bear in mind that this comes at a risk of complications that cannot be reduced to zero.

Dual-action CXCR4-targeting liposomes in leukemia: function blocking and drug delivery.

CXC chemokine receptor 4 (CXCR4) is overexpressed by a broad range of hematological disorders, and its interaction with CXC chemokine ligand 12 (CXCL12) is of central importance in the retention and chemoprotection of neoplastic cells in the bone marrow and lymphoid organs. In this article, we describe the biological evaluation of a new CXCR4-targeting and -antagonizing molecule (BAT1) that we designed and show that, when incorporated into a liposomal drug delivery system, it can be used to deliver cancer therapeutics at high levels to chronic lymphocytic leukemia (CLL) cells. CXCR4 targeting and antagonism by BAT1 were demonstrated alone and following its incorporation into liposomes (BAT1-liposomes). Antagonism of BAT1 against the CXCR4/CXCL12 interaction was demonstrated through signaling inhibition and function blocking: BAT1 reduced ERK phosphorylation and cell migration to levels equivalent to those seen in the absence of CXCL12 stimulation (P < .001). Specific uptake of BAT1-liposomes and delivery of a therapeutic cargo to the cell nucleus was seen within 3 hours of incubation and induced significantly more CLL cell death after 24 hours than control liposomes (P = .004). The BAT1 drug-delivery system is modular, versatile, and highly clinically relevant, incorporating elements of proven clinical efficacy. The combined capabilities to block CXCL12-induced migration and intracellular signaling while simultaneously delivering therapeutic cargo mean that the BAT1-liposome drug-delivery system could be a timely and relevant treatment of a range of hematological disorders, particularly because the therapeutic cargo can be tailored to the disease being treated.

Outcomes After Hemiarthroplasty of the Elbow for the Management of Posttraumatic Arthritis: Minimum 2-Year Follow-up.

BACKGROUND: Hemiarthroplasty (HA) of the elbow represents an alternative to total elbow arthroplasty (TEA) without the associated activity restrictions. This study reviews our experience with distal humerus HA with minimum 2-year follow-up. METHODS: Between 2002 and 2012, 16 elbows underwent HA for posttraumatic arthritis of the elbow. Patients were followed for a minimum of 2 years or until revision surgery. Outcome measures included pre- and postoperative Mayo Elbow Performance Scores (MEPSs), complications, and revisions. RESULTS: Mean age at arthroplasty was 45 years, and follow-up averaged 51 months. All patients had previously undergone one or more surgical procedures at the elbow (average of 1.5 procedures). At follow-up, five had undergone additional surgery; two were revised to TEA. In surviving implants, the range of motion at follow-up was markedly improved from preoperative motion. The MEPS for the remaining HA included five excellent results, three good results, five fair results, and one poor result. DISCUSSION: Elbow HA is an option for young or active patients with end-stage elbow posttraumatic arthritis who are unwilling to accept activity limitations. However, high rates of revision surgery and revision to TEA occur after HA for posttraumatic osteoarthritis of the elbow. Only 57% of patients with surviving implants had a good to excellent MEPS, although improvement in the range of motion was predictable.

Oil toxicity test methods must be improved.

A review of the literature on oil toxicity tests showed a high diversity of reported test methods that may affect the composition, stability, and toxicity of oil solutions. Concentrations of oil in test solutions are dynamic because hydrocarbons evaporate, partition to test containers, bioaccumulate, biodegrade, and photo-oxidize. As a result, the composition and toxicity of test solutions may vary widely and create significant obstacles to comparing toxicity among studies and to applying existing data to new risk assessments. Some differences in toxicity can be resolved if benchmarks are based on measured concentrations of hydrocarbons in test solutions, highlighting the key role of chemical analyses. However, analyses have often been too infrequent to characterize rapid and profound changes in oil concentrations and composition during tests. The lack of practical methods to discriminate particulate from dissolved oil may also contribute to underestimating toxicity. Overall, current test protocols create uncertainty in toxicity benchmarks, with a high risk of errors in measured toxicity. Standard oil toxicity tests conducted in parallel with tests under site-specific conditions would provide an understanding of how test methods and conditions affect measured oil toxicity. Development of standard test methods could be achieved by collaborations among university, industry, and government scientists to define methods acceptable to all 3 sectors. Environ Toxicol Chem 2019;38:302-311. © 2018 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals, Inc. on behalf of SETAC.

Synthesis and biological activity of a CXCR4-targeting bis(cyclam) lipid.

A bis(cyclam)-capped cholesterol lipid designed to bind C-X-C chemokine receptor type 4 (CXCR4) was synthesised in good overall yield from 4-methoxyphenol through a seven step synthetic route, which also provided a bis(cyclam) intermediate bearing an octaethyleneglycol-primary amine that can be easily derivatised. This bis(cyclam)-capped cholesterol lipid was water soluble and self-assembled into micellar and non-micellar aggregates in water at concentrations above 8 µM. The bioactivity of the bis(cyclam)-capped cholesterol lipid was assessed using primary chronic lymphocytic leukaemia (CLL) cells, first with a competition binding assay then with a chemotaxis assay along a C-X-C motif chemokine ligand 12 (CXCL12) concentration gradient. At 20 µM, the bis(cyclam)-capped cholesterol lipid was as effective as the commercial drug AMD3100 for preventing the migration of CLL cells, despite a lower affinity for CXCR4 than AMD3100.

Hemiarthroplasty Is an Option for Patients Older Than 70 Years With Glenohumeral Osteoarthritis.

Hemiarthroplasty (HA) of the shoulder has several potential advantages over total shoulder arthroplasty (TSA), particularly in the elderly population. This study reviewed long-term results of HA and TSA in patients older than 70 years with glenohumeral osteoarthritis. During a 30-year period, 403 shoulders had undergone HA (n=74) or TSA (n=329) for glenohumeral osteoarthritis. Outcome measures included pain, range of motion, and postoperative modified Neer ratings. All patients were included in the mortality and revision analyses. A total of 289 shoulders (44 HAs and 245 TSAs; mean patient age, 75 years) with a minimum of 5 years of follow-up or follow-up until revision were included. Both groups showed significant improvements in pain, abduction, and external rotation. No significant differences were detected between groups in postoperative pain, range of motion, or modified Neer ratings. Operative time was significantly lower in the HA group. There was no statistically significant difference detected in implant revision-free survival between TSA and HA (hazard ratio, 3.09) or in overall survival hazard ratio. At long-term follow-up, both HAs and TSAs provided good function in the elderly population. Patients who underwent TSA and patients who underwent HA had similar results, but the latter had a shorter operative time and lower revision rate. Hemiarthroplasty is a reasonable option for patients older than 70 years with end-stage glenohumeral osteoarthritis. [Orthopedics. 2018; 41(4):222-228.].

Late Reconstruction of the Interosseous Membrane with Bone-Patellar Tendon-Bone Graft for Chronic Essex-Lopresti Injuries: Outcomes with a Mean Follow-up of Over 10 Years.

BACKGROUND: The purpose of this study was to report our long-term outcomes following reconstruction of the forearm interosseous membrane (IOM) with bone-patellar tendon-bone (BPTB) graft for treatment of chronic Essex-Lopresti injuries. METHODS: We identified 33 patients who underwent IOM reconstruction with BPTB graft for chronic Essex-Lopresti injuries over a 20-year treatment interval. Twenty male and 13 female patients, with a mean age of 42.1 years (range, 19 to 73 years) and a minimum follow-up interval of 5 years, were included. Preinjury clinical examination and radiographic measurements were obtained from records for comparison with prospectively collected data. Additional functional outcome data collected postoperatively included QuickDASH (an abbreviated version of the Disabilities of the Arm, Shoulder and Hand [DASH]), modified Mayo wrist (MMW), and Broberg-Morrey elbow function scores. RESULTS: IOM reconstruction was performed at a mean interval (and standard deviation) of 44.9 ± 60.0 months (range, 6.4 to 208 months) from the time of the initial injury. At a mean follow-up of 10.9 ± 4.4 years (range, 5.5 to 24.2 years), significant improvements were observed in mean elbow flexion-extension arc (+13° [95% confidence interval (CI), 4° to 22°]; p = 0.005), wrist flexion-extension arc (+19° [95% CI, 4° to 34°]; p = 0.016), forearm pronation-supination (+23° [95% CI, 8° to 39°]; p = 0.004), and grip strength (+25% of that of the contralateral side [95% CI, 18% to 32% of contralateral side]; p < 0.001). Improvements in ulnar variance were sustained over the long term from +3.9 mm (95% CI, 3.2 to 4.6 mm) preoperatively to -1.6 mm (95% CI, -2.3 to -0.9 mm) immediately postoperatively and -1.1 mm (95% CI, -1.8 to -0.4 mm) at the time of the final follow-up (p < 0.001). The mean QuickDASH, MMW, and Broberg-Morrey scores were 29.8 (range, 5 to 61), 82.7 (range, 60 to 100), and 91.6 (range, 64 to 100), respectively. CONCLUSIONS: IOM reconstruction with a BPTB graft is an effective treatment option for chronic Essex-Lopresti injuries, with satisfactory clinical and functional outcomes over the long term. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.