Medical Faculty and Medical Student Opinions on the Utility of Questions to Teach and Evaluate in the Clinical Environment.

Objectives: We sought to report medical student and faculty perceptions of the purpose and utility of questions on clinical rounds. Methods: We developed and administered a survey to third and fourth-year medical students and teaching physicians. The survey elicited attitudes about using questions to teach on rounds in both benign and malignant learning environments. Results: Ninety-seven percent of faculty and 85% of students predicted they will use questions to teach. Nine percent of students described learning-impairing stress during benign bedside teaching. Fifty-nine percent of faculty felt questions were mostly for teaching; 74% of students felt questions were mostly for evaluation. Forty-six percent of students felt questions underestimated their knowledge. Students felt questions were more effective for classroom teaching than bedside teaching. Faculty and students agreed that a malignant environment detrimentally affected learning and performance. Conclusions: Students and faculty supported the use of questions to teach and evaluate, especially in benign teaching environments. Many students described stress severe enough to affect their learning and performance, even when questioned in benign teaching environments. Faculty underestimated the degree to which students experience stress-related learning impairment and the degree to which students see questions as evaluation rather than teaching. Nearly half of students felt that questions underestimated their own knowledge. Students feel more stress and less learning when questioned with a patient present. Faculty must realize that even in the best learning environment some students experience stress-impaired learning and performance, perhaps because of the conflict between learning and evaluation.

The obesity paradox and orthopedic surgery.

ABSTRACT: The Obesity Paradox describes the counterintuitive finding that although obesity contributes to the development of chronic conditions such as chronic kidney disease and cardiovascular disease, obesity seems to improve mortality in patients with these diseases. This paradox has also been sited in the critical care literature in regard to acute kidney injury, obesity and mortality. This study's objective is to examine the impact of obesity and post-surgical acute kidney injury on hospital length of stay and 2-year mortality after orthopedic surgery.We reviewed the electronic medical records of all adult elective orthopedic surgery patients over 2 years in a large academic hospital. The 1783 patients who met inclusion criteria were divided into obese (body mass index, BMI ≥ 30, n = 1123) and non-obese groups (BMI <30, n = 660). Demographics, medications, comorbidities, and perioperative variables were included in multivariable logistic regression analyses with acute kidney injury, length of hospital stay, and two-year mortality as primary outcomes. Outcomes were analyzed for the entire group, the obese cohort and the non-obese cohort.Acute kidney injury developed in 5% of the post-surgical orthopedic patients. Obesity increased the likelihood of developing acute kidney injury post orthopedic surgery (odds ratio [OR] = 1.82; 95% Confidence interval [CI] 1.05-3.15, P = .034). Acute kidney injury increased length of stay by 1.3 days and increased the odds of two-year mortality (OR = 2.08; 95% CI 1.03-4.22, P = .041). However, obese patients had a decreased likelihood of two-year mortality (OR = 0.53; 95% CI 0.33-0.84, P = .009).In adult orthopedic surgery patients, obesity increased the risk of acute kidney injury. Patients who developed an acute kidney injury had longer hospital stays and higher two-year mortality. Paradoxically, obesity decreased two-year mortality.

A comparison of orthopaedic surgery and internal medicine perceptions of USMLE Step 1 pass/fail scoring.

BACKGROUND: United States Medical Licensing Examination Step 1 will transition from numeric grading to pass/fail, sometime after January 2022. The aim of this study was to compare how program directors in orthopaedics and internal medicine perceive a pass/fail Step 1 will impact the residency application process. METHODS: A 27-item survey was distributed through REDCap to 161 U.S. orthopaedic residency program directors and 548 U.S. internal medicine residency program directors. Program director emails were obtained from the American Medical Association's Fellowship and Residency Electronic Interactive Database. RESULTS: We received 58 (36.0%) orthopaedic and 125 (22.8%) internal medicine program director responses. The majority of both groups disagree with the change to pass/fail, and felt that the decision was not transparent. Both groups believe that the Step 2 Clinical Knowledge exam and clerkship grades will take on more importance. Compared to internal medicine PDs, orthopaedic PDs were significantly more likely to emphasize research, letters of recommendation from known faculty, Alpha Omega Alpha membership, leadership/extracurricular activities, audition elective rotations, and personal knowledge of the applicant. Both groups believe that allopathic students from less prestigious medical schools, osteopathic students, and international medical graduates will be disadvantaged. Orthopaedic and internal medicine program directors agree that medical schools should adopt a graded pre-clinical curriculum, and that there should be a cap on the number of residency applications a student can submit. CONCLUSION: Orthopaedic and internal medicine program directors disagree with the change of Step 1 to pass/fail. They also believe that this transition will make the match process more difficult, and disadvantage students from less highly-regarded medical schools. Both groups will rely more heavily on the Step 2 clinical knowledge exam score, but orthopaedics will place more importance on research, letters of recommendation, Alpha Omega Alpha membership, leadership/extracurricular activities, personal knowledge of the applicant, and audition electives.

Pre-operative echocardiograms in acute fragility hip fractures: How effective are the guidelines?

ABSTRACT: In 2014, the American College of Cardiology/American Heart Association (ACC/AHA) released guidelines for ordering pre-operative echocardiograms in patients undergoing non-cardiac surgery. The purpose of this study is to determine if pre-operative echocardiograms ordered prior to fragility hip fracture repair are ordered according to these guidelines, change anesthetic management or affect patient outcomes. In addition, we attempted to evaluate the efficacy of the ACC/AHA guidelines.We conducted a 4-year retrospective chart review of acute fragility hip fractures at a single institution. Charts were reviewed to determine which patients met criteria for a pre-operative echocardiogram. Within this group we then compared patients who received a pre-operative echocardiogram to those who did not. Comparisons were made with regard to time to surgery, changes from standard anesthetic management, major adverse cardiac events, length of hospital stay, and 1-year mortality. We also examined which patients received postoperative echocardiograms and the incidence of adverse cardiac events in this group.Of 402 patients, 87 (22%) had ACC/AHA indications for pre-operative echocardiogram, and 42 (48%) of them received one. The indication to order a pre-operative echocardiogram in stable heart failure or valve disease patients if their last echo was greater than 1 year was only followed 23% of the time. In the pre-operative echocardiogram group, anesthetic management was adjusted more frequently (P = .025), and average time to surgery was greater (P < .001). The incidence of a major adverse cardiac event was 10% in the ACC/AHA echocardiogram indicated group and 3% in the non-indicated echocardiogram group. An equal number of echocardiograms were completed postoperatively as were completed under ACC/AHA pre-operative guidelines. Sixty-seven percent of the postoperative echocardiograms did not have ACC/AHA pre-operative indications.Our data demonstrates that pre-operative echocardiograms for "stable heart failure and valvular disease with greater than 1 year from last echocardiogram" is infrequently performed without significant adverse cardiac outcomes. Pre-operative echocardiography was associated with more anesthetic adjustments and longer time to surgery. Postoperative echocardiograms were done for cardiopulmonary complications. Studies need to examine and refine clinical parameters that would improve the selection of patients who would benefit from pre-operative echocardiograms.

Modern Day Scurvy in Pediatric Orthopaedics: A Forgotten Illness.

INTRODUCTION: Scurvy, or vitamin C deficiency, is rare. The goal of this study is to highlight the common risk factors and identify the orthopaedic presentation of scurvy in children. METHODS: A retrospective chart and radiograph review was performed of all patients consulted to the pediatric orthopaedic service from 2010 to 2019 who ultimately had the diagnosis of scurvy confirmed by an abnormally low serum vitamin C level. Data extracted included: patient age, sex, neurological conditions, prematurity, psychiatric conditions, dietary abnormalities, bone pain, arthritis, limb swelling, inability to walk, skin changes, child abuse evaluations, radiographic findings, additional vitamin deficiencies, lab studies, additional tests, response to treatment. Descriptive statistics were performed. RESULTS: Nine patients (7 males, 2 females) with scurvy were studied. The average age was 7 years (range 3 to 13 y). The average body mass index was 21.4 (range, 14 to 30). Five had autism, 2 had a neurological disorder. Two had been born premature. Two had a psychiatric disorder. Seven had an abnormal diet. One presented with bone pain. Four presented with limb swelling. Seven had unilateral and 2 had bilateral leg symptoms. Five presented with inability to walk. Six demonstrated skin changes with ecchymosis or petechiae. Three presented with gingival bleeding. Radiographic findings included subperiosteal hematoma in 2, ring epiphysis in 3, Pelkan spurs in 1, metaphyseal white lines (Frankel sign) in 6, and a metaphyseal zone of rarefaction (Trummerfeld zone) in 3. Seven had additional vitamin deficiencies including: A, B1, B6, B9, D, E, K, iron and zinc. Four had a bone marrow biopsy and 1 had lumbar puncture. All were anemic. The average erythrocyte sedimentation rate was 25.7 (range 6 to 35) and C-reactive protein was 1.5 (range 0.55 to 5.64). Six had a computed tomography, 3 had a magnetic resonance imaging. After treatment with vitamin C lasting 3.4 months (range, 2 wk to 7 mo), all symptoms gradually resolved, including leg pain and swelling. All children began to walk. CONCLUSION: The pediatric orthopaedic surgeon should have an increased awareness about the diagnosis of scurvy when consulted on a child with bone pain or inability to walk. The most common orthopaedic presentation was the refusal to bear weight, the most common radiographic finding was the metaphyseal line of increased density (Frankel sign) and treatment with vitamin c supplementation was excellent in all cases.

Obesity, Angiotensin-Blocking Drugs, and Acute Kidney Injury in Orthopedic Surgery.

Postoperative acute kidney injury occurs in 7% to 11% of orthopedic surgeries. The effect of preoperative angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) on the development of postoperative acute kidney injury remains controversial. Adipose tissue has its own independently regulated angiotensin system. The primary aim of this study was to examine the effects of obesity and preoperative ACEIs and ARBs on postoperative acute kidney injury. Charts were reviewed of adult elective orthopedic surgery patients during a 2-year period when patients were instructed to take their ACEI or ARB on the morning of surgery. The patients were divided into an obese cohort (body mass index [BMI] ≥30 kg/m2) and a nonobese cohort (BMI <30 kg/m2). A multivariable model was created for the outcome of acute kidney injury, using obesity as a primary predictor and adjusting for demographics, medications, comorbidities, and intraoperative parameters in a logistic regression analysis. Obesity increased the likelihood of developing acute kidney injury after orthopedic surgery (odds ratio [OR], 1.86; 95% CI, 1.07-3.22; P=.028). For every 5-unit increase in BMI, the odds of acute kidney injury were 1.43 (95% CI, 1.26-1.62; P<.001). When receiving ACEIs or ARBs, only the nonobese patients had a statistically increased likelihood of postoperative acute kidney injury (OR, 3.30; 95% CI, 1.12-9.70; P=.030). Obesity is an independent risk factor for postoperative acute kidney injury. Obesity appears to influence the effect that preoperative ACEIs and ARBs have on postoperative acute kidney injury. [Orthopedics. 2021;44(2):e253-e258.].

A survey of US hospitals' criteria for the allocation of remdesivir to treat COVID-19.

PURPOSE: To determine how hospitals across the United States determined allocation criteria for remdesivir, approved in May 2020 for treatment of coronavirus disease 2019 (COVID-19) through an emergency use authorization, while maintaining fair and ethical distribution when patient needs exceeded supply. METHODS: A electronic survey inquiring as to how institutions determined remdesivir allocation was developed. On June 17, 2020, an invitation with a link to the survey was posted on the Vizient Pharmacy Network Community pages and via email to the American College of Clinical Pharmacy's Infectious Disease Practice and Research Network listserver. RESULTS: 66 institutions representing 28 states responded to the survey. The results showed that 98% of surveyed institutions used a multidisciplinary team to develop remdesivir allocation criteria. A majority of those teams included clinical pharmacists (indicated by 97% of respondents), adult infectious diseases physicians (94%), and/or adult intensivists (69%). Many teams included adult hospitalists (49.2%) and/or ethicists (35.4%). Of the surveyed institutions, 59% indicated that all patients with COVID-19 were evaluated for treatment, and 50% delegated initial patient identification for potential remdesivir use to treating physicians. Prioritization of remdesivir allocation was often determined on a "first come, first served" basis (47% of respondents), according to a patient's respiratory status (28.8%) and/or clinical course (24.2%), and/or by random lottery (22.7%). Laboratory parameters (10.6%), comorbidities (4.5%), and essential worker status (4.5%) were rarely included in allocation criteria; no respondents reported consideration of socioeconomic disadvantage or use of a validated scoring system. CONCLUSION: The COVID-19 pandemic has exposed the inconsistencies of US medical centers' methods for allocating a limited pharmacotherapy resource that required rapid, fair, ethical and equitable distribution. The medical community, with citizen participation, needs to develop systems to continuously reevaluate criteria for treatment allocation as additional guidance and data emerge.

Prevalence, Timing, Causes, and Outcomes of Hyponatremia in Hospitalized Orthopaedic Surgery Patients.

BACKGROUND: Hyponatremia is common among orthopaedic patients and is associated with adverse clinical outcomes. We examined the prevalence, timing, causes, and outcomes of hyponatremia in adult hospitalized orthopaedic surgery patients. METHODS: We evaluated the medical records of 1067 consecutive orthopaedic surgery patients admitted to a tertiary academic institution. The medical records were reviewed to investigate hyponatremia (serum sodium <135 mEq/L) that (1) had been present on hospital admission or (2) had developed postoperatively. The primary outcomes were the prevalence and timing of, and risk factors for, presentation with or development of hyponatremia. Secondary outcomes were hospital length of stay, total hospital cost, and discharge disposition. Multivariable logistic regression models were used to assess the variables associated with hyponatremia and the effects of hyponatremia on clinical outcomes. RESULTS: Of the 1067 patients, seventy-one (7%) had preoperative hyponatremia and 319 (30%) developed hyponatremia postoperatively. Of the latter, 298 (93%) developed hyponatremia within forty-eight hours postoperatively. Compared with patients with normonatremia, those who presented with hyponatremia, on the average, were older (67.2 versus 60.5 years, p < 0.001), had longer hospital stays (4.6 versus 3.3 days, p < 0.001), incurred higher hospital costs ($19,200 versus $17,000, p = 0.006), and were more likely to be discharged to an extended-care facility (odds ratio [OR] = 2.87, p < 0.001). Developing hyponatremia postoperatively resulted, on average, in a longer hospital stay (3.7 versus 3.3 days, p = 0.002) and greater hospital cost ($18,800 versus $17,000, p < 0.001). Age (OR = 1.13 per decade, p = 0.012), spine surgery (OR = 2.76 versus knee, p < 0.001), hip surgery (OR = 1.76 versus knee, p < 0.001), and the amount of lactated Ringer solution used (OR = 1.16, p = 0.002) increased the risk of developing hyponatremia. CONCLUSIONS: Hyponatremia in orthopaedic patients is associated with longer, costlier hospitalizations. The factors that significantly increased the risk of developing postoperative hyponatremia were an older age, spine fusion, hip arthroplasty, and the amount of lactated Ringer solution used.

Angiotensin axis blockade, hypotension, and acute kidney injury in elective major orthopedic surgery.

BACKGROUND: Patients presenting for surgery with angiotensin axis blockade (AAB) from therapy with either angiotensin-converting enzyme inhibitors or angiotensin receptor blockers experience an increased incidence of perioperative hypotension. Acute kidney injury (AKI) in patients receiving preoperative AAB has been demonstrated after lung, vascular, and cardiac surgery. However, there is little literature evaluating the hypotensive and renal effects of preoperative AAB and major orthopedic surgery. METHODS: We performed a retrospective chart review of 1154 patients who underwent spinal fusion, total knee arthroplasty, or total hip arthroplasty during the 2010 calendar year in our academic medical center. RESULTS: A total of 922 patients met inclusion criteria, 343 (37%) received preoperative AAB. Postinduction hypotension (systolic blood pressure ≤80 mm Hg for 5 minutes) was significantly higher in patients receiving AAB when compared to those not so treated (12.2% vs 6.7%; odds ratio [OR]: 1.93, P = 0.005). Of the 922 patients, 798 had documented measurements of both preoperative and postoperative creatinine. Postoperative AKI was significantly higher in patients receiving AAB therapy (8.3% vs 1.7%; OR: 5.40, P < 0.001), remaining significant after adjusting for covariates including hypotension (OR: 2.60, P = 0.042). Developing AKI resulted in a significantly higher mean length of stay (5.76 vs 3.28 days, P < 0.001) but no difference in 2-year mortality. CONCLUSIONS: Patients undergoing major elective orthopedic surgery who receive preoperative AAB therapy,have an associated increased risk of postinduction hypotension and postoperative acute kidney injury resulting in a greater hospital length of stay.

Sports preparticipation examination to screen college athletes for Chlamydia trachomatis.

PURPOSE: This study assessed the prevalence of Chlamydia trachomatis in the college athlete and the benefit of using the sports preparticipation examination (PPE) as a screening opportunity. METHODS: Chlamydia teaching and screening was part of the sports PPE. The 439 athletes (220 men and 219 women) answered a questionnaire and provided urine specimens. Using positive test results as an indication of prevalence, the chlamydia prevalence rate was calculated by sex and race. Using the questionnaire responses, we determined the students' accessibility to health care and the percentage of sexually active students who were ever offered chlamydial screening. RESULTS: Thirteen of 439 athletes tested positive. One test was a false positive. The test positivity was 2.7%: 3.2% men and 2.2% women. In sexually active athletes, the test positivity rose to 3.8%: 4.0% men and 3.7% women. African American athletes had a higher prevalence of 9.1%: 8.9% in men and 9.5% in women, making them six times more likely to have chlamydia than Caucasian athletes (odds ratio = 6.43, 95% confidence interval = 1.58-30.55). Number of partners, contraceptive type, symptoms, and prior history of chlamydia were not statistically different between groups. Over 75% of students saw their private physicians, yet of the sexually active students, only 31% of women and 6.8% of men were ever offered chlamydial screening. CONCLUSIONS: The Centers for Disease Control and Prevention and the U.S. Preventive Services Task Force guidelines recommending annual chlamydial screening for all sexually active women younger than 26 yr are not being met in the community. Taking advantage of opportunities, including the mandated sports PPE, where sexually active men and women 25 yr and younger interface with the health care system to screen for C. trachomatis, is crucial to decreasing the continued rise of chlamydial infection.