Telemedicine in orthopaedics during the COVID-19 pandemic: a comparative landscape.

PURPOSE: The purpose of this study was to provide a comprehensive analysis on observed trends regarding the impact of the COVID-19 pandemic on telemedicine application in orthopaedics compared to other procedural, non-emergent specialties. METHODS: This was a retrospective review of all telemedicine and in-person visits at a large single institution from January to December 2020. The number of patient visits, visit type, location, and provider specifics were collected. Comparisons were made between subspecialties (orthopaedic surgery, oncology, family medicine, rheumatology) for analyses. RESULTS: All specialties included were not conducting virtual visits at the beginning of 2020. By April 2020, orthopaedic virtual visits spiked to an all-time high of 33.5% of all patient visits as compared to oncology at 25.5%, rheumatology at 92.9%, and family medicine at 94%. By the end of the study period, orthopaedic virtual visits decreased back down to 6.5% of patient visits compared to oncology at 7.0%, and family medicine (17.4%) and rheumatology (26.2%). Orthopaedic providers practicing greater than 20 years had the highest average virtual visit rates. CONCLUSION: Although the COVID-19 pandemic has posed unique challenges for healthcare providers, there was a great advancement in the rollout and application of telemedicine. To mitigate the spread of infection from coronavirus and given the recent adjustments to reimbursement policies and HIPAA regulations, orthopaedics saw a dramatic expansion of telemedicine since April 2020. The pandemic may have served as a catalyst to adopt telehealth into clinical practice. However, telehealth saw a downtrend trend by December 2020, particularly in procedure-based fields like orthopaedics and oncology.

Nanocrystalline Silver Layer of Knitted Polyester Outperforms Other Silver-Containing Wound Dressings in an In Vitro Wound Model.

Background Silver possesses cytotoxic properties against many microorganisms and is regularly used in wound care. Current evidence supporting the use of one type of silver-containing wound dressing (SCWD) is insufficient. Materials and methods To examine the ability of selected SCWDs to inhibit the growth of two strains of bacteria (Escherichia coli and Staphylococcus aureus) commonly found in wounds, an in vitro wound model was used. Bacteria were applied to the surface of nutrient agar, and a piece of each SCWD was applied to the bacteria. The plates were incubated at 37°C overnight. The zone of inhibition (ZI) around each SCWD was measured in cm2. Results The mean ZI for Acticoat Flex-3 on E. coli was 1.59 ± 0.15 cm2, which was significantly greater than that observed for Aquacel Ag (p<0.001), Mepilex Ag (p<0.0001), Mepitel Ag (p<0.001), Optifoam (p<0.0001), and Tegaderm Alginate Ag (p<0.01), but statistically indistinguishable from Maxorb II Ag. The mean ZI on S. aureus was 1.21 ± 0.16 cm2, which was greater than Aquacel Ag (p<0.05), Mepilex (p<0.0001), Optifoam (p<0.0001), and Tegaderm Alginate Ag (p<0.05), but statistically indistinguishable from Maxorb II Ag or Mepitel Ag. Conclusion Of the SCWDs tested, Acticoat Flex-3 demonstrated the most robust antimicrobial effect. Herein, we show that Acticoat Flex-3 may provide the most wound protection against bacterial infection. In conclusion, these data provide clinicians with additional independent evidence to inform their clinical practice on the use of specific wound dressings.

Needs, Challenges, and Applications of Artificial Intelligence in Medical Education Curriculum.

Artificial intelligence (AI) is on course to become a mainstay in the patient's room, physician's office, and the surgical suite. Current advancements in health care technology might put future physicians in an insufficiently equipped position to deal with the advancements and challenges brought about by AI and machine learning solutions. Physicians will be tasked regularly with clinical decision-making with the assistance of AI-driven predictions. Present-day physicians are not trained to incorporate the suggestions of such predictions on a regular basis nor are they knowledgeable in an ethical approach to incorporating AI in their practice and evolving standards of care. Medical schools do not currently incorporate AI in their curriculum due to several factors, including the lack of faculty expertise, the lack of evidence to support the growing desire by students to learn about AI, or the lack of Liaison Committee on Medical Education's guidance on AI in medical education. Medical schools should incorporate AI in the curriculum as a longitudinal thread in current subjects. Current students should understand the breadth of AI tools, the framework of engineering and designing AI solutions to clinical issues, and the role of data in the development of AI innovations. Study cases in the curriculum should include an AI recommendation that may present critical decision-making challenges. Finally, the ethical implications of AI in medicine must be at the forefront of any comprehensive medical education.

Recognising immunotherapy-induced meningoencephalitis: a case during treatment for primary metastatic melanoma of the bladder neck.

Although novel immunotherapy has shown promise for patients with melanoma, a more activated state of the immune system may lead to adverse systemic effects. Immunotherapy-induced meningoencephalitis is a rare and seldom reported adverse effect of immunotherapy but with the expanding role of immunotherapy in cancer treatments it must be recognised. Patients receiving immunotherapy should receive a proper warning about the potential for this life-threatening condition. Herein, we report a patient in his 70s with neurological changes after his second treatment with dual immunotherapy for a primary metastatic melanoma of the bladder neck.

Renal malakoplakia with invasion of the liver and diaphragm: a patient case and literature review.

Renal malakoplakia, a seldom seen chronic inflammatory condition, continues to elude medical, surgical, radiological and pathological specialists due to its mimicry of other renal pathologies and low incidence. The variable clinical manifestations and non-specific radiological findings of malakoplakia can be misleading, and ultimately require a pathological diagnosis. A literature review reveals an extremely low prevalence of renal malakoplakia, a handful of invasive renal malakoplakia cases and no reports of liver and diaphragmatic invasion. We present a case of a renal mass with liver and diaphragmatic invasion in a 59-year-old woman that deceived clinicians and radiologists until a pathological diagnosis of renal malakoplakia was performed. This case highlights the need of awareness for malakoplakia in the differential diagnosis for renal invasive and non-invasive masses. The need to await a surgical biopsy and pathological diagnosis is critical to ensure a correct diagnosis and avoid unnecessary surgery of the kidney.

Educating Future Physicians in Artificial Intelligence (AI): An Integrative Review and Proposed Changes.

BACKGROUND: As medicine and the delivery of healthcare enters the age of Artificial Intelligence (AI), the need for competent human-machine interaction to aid clinical decisions will rise. Medical students need to be sufficiently proficient in AI, its advantages to improve healthcare's expenses, quality, and access. Similarly, students must be educated about the shortfalls of AI such as bias, transparency, and liability. Overlooking a technology that will be transformative for the foreseeable future would place medical students at a disadvantage. However, there has been little interest in researching a proper method to implement AI in the medical education curriculum. This study aims to review the current literature that covers the attitudes of medical students towards AI, implementation of AI in the medical curriculum, and describe the need for more research in this area. METHODS: An integrative review was performed to combine data from various research designs and literature. Pubmed, Medline (Ovid), GoogleScholar, and Web of Science articles between 2010 and 2020 were all searched with particular inclusion and exclusion criteria. Full text of the selected articles was analyzed using the Extension of Technology Acceptance Model and the Diffusions of Innovations theory. Data were successively pooled together, recorded, and analyzed quantitatively using a modified Hawkings evaluation form. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses was utilized to help improve reporting. RESULTS: A total of 39 articles meeting inclusion criteria were identified. Primary assessments of medical students attitudes were identified (n = 5). Plans to implement AI in the curriculum for the purpose of teaching students about AI (n = 6) and articles reporting actual implemented changes (n = 2) were assessed. Finally, 26 articles described the need for more research on this topic or calling for the need of change in medical curriculum to anticipate AI in healthcare. CONCLUSIONS: There are few plans or implementations reported on how to incorporate AI in the medical curriculum. Medical schools must work together to create a longitudinal study and initiative on how to successfully equip medical students with knowledge in AI.

The impact of state-mandated opioid prescribing restrictions on prescribing patterns surrounding reverse total shoulder arthroplasty.

BACKGROUND: Orthopedic surgeons are the third-highest prescribers of opioid medications, and the recent opioid crisis has placed more scrutiny on physicians and their prescribing habits. House Bill 21, a new law limiting the prescription of opioid medications, was signed in Florida on July 1, 2018 and similar laws have been passed in a number of other states as well. The purpose of this study was to understand the effect of new legal mandates on opioid prescribing patterns and dependence rates for patients undergoing reverse shoulder arthroplasty. METHODS: A retrospective review of 143 patients who underwent primary reverse shoulder arthroplasty from 2017 to 2019 was performed. There were 87 patients in the pre-legislation group (group 1), compared to 56 in the post-legislation group (group 2). Demographics data and opioid prescriptions provided 90 days before and after surgery were obtained using the physician drug monitoring database. Descriptive statistics and Student's t-tests were used to examine differences. RESULTS: Preoperatively, both groups received similar numbers of pills and total morphine equivalents (TMEs; group 1: 47.3 pills and 59.9 TMEs, group 2: 30.9 pills and 24.8 TMEs) (P = .292, P = .081). Group 1 had 88.5% of patients fill an opioid prescription postoperatively, compared to 50.9% of group 2 (P < .001). Postoperatively, initial opioid prescriptions were higher in average pills for group 1 (26 pills with an average of 375.6 TMEs) compared to group 2 (18 pills with an average of 199.6 TMEs) (P < .001, P = .122). For the entire postoperative course, patients in group 1 filled prescriptions for an average of 1740.7 TMEs and 84 pills, compared to 461.9 TMEs and 32 pills in group 2 (P = .035, P < .001). In the cohort, 17.8% of group 2 had multiple recorded opioid prescriptions, compared to 70.1% of group 1. There were also significant differences observed in postoperative dependence rates, with 23.0% in group 1 compared to 12.5% in group 2 (P = .043). CONCLUSIONS: State-mandated opioid prescribing restrictions have been successful in decreasing opioid prescribing and dependence rates for orthopedic shoulder patients. Further efforts are required to reduce preoperative prescriptions involving chronic shoulder pathology as current legislature has not had an impact on this. Legislative changes may be an effective way to help reduce abuse and opioid dependence in shoulder arthroplasty patients; however, further research is needed.

MD and DO: Differing Medical Degrees and the Associated Perceptions.

PURPOSE: To highlight perspectives about differing medical degrees and graduate medical education amongst current allopathic (MD) and osteopathic (DO) radiology residents. MATERIALS AND METHOD: Two hundred sixty-eight radiology residents were interviewed using an approved Association of Program Coordinators in Radiology (APCR) survey designed to evaluate perceptions of allopathic and osteopathic radiology residents regarding type of medical degree and their career development. The surveys were kept anonymous with no identifiable information. Residents in their first through fourth years of training replied with an approximate equal distribution amongst the different years. RESULTS: Based on the 268 respondents, DOs' more so than MDs', reported that their degree type altered their medical careers (P < 0.0001) and that they were advised to not pursue a radiology residency based on degree type (P< 0.0001). In addition, a large majority of both DOs' and MDs' felt that residency selection is favored towards the allopathic degree (P= 0.0451). CONCLUSION: This survey-based study does reveal perceived differences in the residency recruitment process based on degree type. Future discussions to bridge this perceived gap will be important, especially in light of the recent ACGME merger between the 2 educational pathways.

Is Community-engaged Learning Possible During a Pandemic: A Call for Culturally Competent Medical Education.

This article was migrated. The article was marked as recommended. Previously, medical school curriculum focused on faculty or physician-led basic science and traditional clinical experiences, with medical students only gaining experience of the community in which they practice during residency. In an effort to enable students to understand US healthcare disparities, the introduction of public health topics regarding marginalized communities and underrepresented individuals have been included in the classroom. However, missing from this shift is the inclusion of authentic public health educational experiences for medical students. These learning experiences are vital to truly understanding the marginalized and discriminated patient populations physicians will encounter. The recent COVID-19 pandemic has brought forth challenges for medical educators in numerous ways including how to effectively prepare students in understanding cultural competency through community-engaged learning for a new set of patient population; the pandemic patient. Due to health disparities, each patient experienced this pandemic differently based on their individual, cultural and community setting; also highlighting the importance of community-engaged learning. Here, the authors posit the role and importance of community-engaged learning in medical education and its utilization during the changing medical landscape due to COVID-19.

Should Radiologists Comment on Incidental Findings of Vascular Calcifications Found on Abdominal/Pelvic CT in Patients Less Than 50 Years of Age?

RATIONALE AND OBJECTIVES: To evaluate if incidental abdominopelvic calcified atherosclerosis (ACA) in patients under 50 years of age correlates with cardiovascular disease (CVD) risk factors. Most studies evaluating calcific atherosclerosis and associated increased risk of CVD have concentrated on middle age and older populations. MATERIALS AND METHODS: A retrospective review of 519 emergency department patients, aged 25-50 years, receiving computed tomography (CT) was performed and ACA correlated with lipid panels obtained via chart review. Those with calcified atherosclerosis were subdivided by vessel location and calcification burden (mild, moderate, or severe). Patients were followed for six years. Normality, Wilcoxon-Mann-Whitney, Kruskal-Wallis, and chi-square tests were performed. RESULTS: Two hundred and sixty-nine patients with incidental ACA on CT and 250 without ACA were studied. Atherosclerotic calcifications had a statistically significant correlation with elevated triglyceride (128 mg/dL vs 105 mg/dL; p = 0.0003) and decreased high-density lipoprotein (38 mg/dL vs 41 mg/dL; p = 0.0032) as compared to the control. Patients with ACA were at higher risk of stroke, heart attack, and death (p < 0.0001) during a six-year follow-up period. CONCLUSION: Incidental atherosclerotic calcification on abdominopelvic CT in patients under 50 years of age correlated with elevated triglycerides and decreased high-density lipoprotein as well as higher risk of cardiovascular events. Since radiologists may be the first to identify this finding and CVD is the leading cause of US deaths, proper recognition and reporting of calcification is valuable.

Macrophages in Nonalcoholic Steatohepatitis: Friend or Foe?

Nonalcoholic steatohepatitis (NASH) is a subtype of nonalcoholic fatty liver disease that is characterised by steatosis, chronic inflammation, and hepatocellular injury with or without fibrosis. The role and activation of macrophages in the pathogenesis of NASH is complex and is being studied for possible therapeutic options to help the millions of people diagnosed with the disease. The purpose of this review is to discuss the pathogenesis of NASH through the activation and role of Kupffer cells and other macrophages in causing inflammation and progression of NASH. Furthermore, this review aims to outline some of the current therapeutic options targeting the pathogenesis of NASH.