Patient Satisfaction with Orthopedic Telemedicine Health Visits During the COVID-19 Pandemic.

Background:Telemedicine usage in orthopedic surgery has seen a dramatic increase as a result of the severe acute respiratory syndrome coronavirus 2 pandemic. The purpose of this study was to examine patient perceptions with telemedicine at a large orthopedic practice.Materials and Methods:An anonymous online survey was distributed to all patients who received a telemedicine health visit at our institution for musculoskeletal complaints from March 17 to June 1, 2020. Responses were scored on a 5-point Likert scale (strongly disagree, disagree, neutral, agree, and strongly agree, 1-5) and analyzed by average score and percent reaching top box.Results:A majority of patients (76.5%) were satisfied with their visit, and only 19.2% did not want telemedicine as a future option. Patients who presented for follow-up visits (4.11 vs. 3.94, p = 0.0053; 48% vs. 41%, p = 0.02) and utilized video (4.21 vs. 3.88, p < 0.001; 51% vs. 39%, p < 0.001) were more satisfied. Average satisfaction between older (>65 years) and younger patients was similar (4.06 vs. 4.06, p = 0.97), however, younger patients were more likely to reach top box (42% vs. 51%, p < 0.001). Confidence that the physician came to the correct diagnosis (r = 0.78, p < 0.001) and receiving the same information and care as an in-office visit (r = 0.60, p < 0.001) demonstrated the strongest correlation with satisfaction and desire for future telemedicine visits, respectively. Interestingly, 31.1% of patients would have sought treatment elsewhere had telemedicine not been an option.Conclusions:Overall, satisfaction rates are high for orthopedic patients undergoing telemedicine visits. Patients are more confident in telemedicine when presenting for a follow-up visit and with the use of video.

An Industry Survey With Focus on Cardiovascular Safety Pharmacology Study Design and Data Interpretation.

INTRODUCTION: The Safety Pharmacology Society (SPS) conducted a membership survey to examine industry practices related mainly to cardiovascular (CV) safety pharmacology (SP). METHODS: Questions addressed nonclinical study design, data analysis methods, drug-induced effects, and conventional and novel CV assays. RESULTS: The most frequent therapeutic area targeted by drugs developed by the companies/institutions that employ survey responders was oncology. The most frequently observed drug-mediated effects included an increased heart rate, increased arterial blood pressure, hERG (IKr) block, decreased arterial blood pressure, decreased heart rate, QTc prolongation, and changes in body temperature. Broadly implemented study practices included Latin square crossover study design with n = 4 for nonrodent CV studies, statistical analysis of data (eg, analysis of variance), use of arrhythmia detection software, and the inclusion of data from all study animals when integrating SP studies into toxicology studies. Most responders frequently used individual animal housing conditions. Responders commonly evaluated drug effects on multiple ion channels, but in silico modeling methods were used much less frequently. Most responders rarely measured the J-Tpeak interval in CV studies. Uncertainties relative to Standard for Exchange of Nonclinical Data applications for data derived from CV SP studies were common. Although available, the use of human induced pluripotent stem cell cardiomyocytes remains rare. The respiratory SP study was rarely involved with identifying drug-induced functional issues. Responders indicated that the study-derived no observed effect level was more frequently determined than the no observed adverse effect level in CV SP studies; however, a large proportion of survey responders used neither.

A Proof-of-Concept Evaluation of JTPc and Tp-Tec as Proarrhythmia Biomarkers in Preclinical Species: A Retrospective Analysis by an HESI-Sponsored Consortium.

INTRODUCTION: Based on the ICH S7B and E14 guidance documents, QT interval (QTc) is used as the primary in vivo biomarker to assess the risk of drug-induced torsades de pointes (TdP). Clinical and nonclinical data suggest that drugs that prolong the corrected QTc with balanced multiple ion channel inhibition (most importantly the l-type calcium, Cav1.2, and persistent or late inward sodium current, Nav1.5, in addition to human Ether-à-go-go-Related Gene [hERG] IKr or Kv11.1) may have limited proarrhythmic liability. The heart rate-corrected J to T-peak (JTpc) measurement in particular may be considered to discriminate selective hERG blockers from multi-ion channel blockers. METHODS: Telemetry data from Beagle dogs given dofetilide (0.3 mg/kg), sotalol (32 mg/kg), and verapamil (30 mg/kg) orally and Cynomolgus monkeys given medetomidine (0.4 mg/kg) orally were retrospectively analyzed for effects on QTca, JTpca, and T-peak to T-end covariate adjusted (Tpeca) interval using individual rate correction and super intervals (calculated from 0-6, 6-12, 12-18, and 18-24 hours postdose). RESULTS: Dofetilide and cisapride (IKr or Kv11.1 blockers) were associated with significant increases in QTca and JTpca, while sotalol was associated with significant increases in QTca, JTpca, and Tpeca. Verapamil (a Kv11.1 and Cav1.2 blocker) resulted in a reduction in QTca and JTpca, however, and increased Tpeca. Medetomidine was associated with a reduction in Tpeca and increase in JTpca. DISCUSSION: Results from this limited retrospective electrocardiogram analysis suggest that JTpca and Tpeca may discriminate selective IKr blockers and multichannel blockers and could be considered in the context of an integrated comprehensive proarrhythmic risk assessment.

Reliability analysis of the AOSpine thoracolumbar spine injury classification system by a worldwide group of naïve spinal surgeons.

PURPOSE: The aims of this study were (1) to demonstrate the AOSpine thoracolumbar spine injury classification system can be reliably applied by an international group of surgeons and (2) to delineate those injury types which are difficult for spine surgeons to classify reliably. METHODS: A previously described classification system of thoracolumbar injuries which consists of a morphologic classification of the fracture, a grading system for the neurologic status and relevant patient-specific modifiers was applied to 25 cases by 100 spinal surgeons from across the world twice independently, in grading sessions 1 month apart. The results were analyzed for classification reliability using the Kappa coefficient (κ). RESULTS: The overall Kappa coefficient for all cases was 0.56, which represents moderate reliability. Kappa values describing interobserver agreement were 0.80 for type A injuries, 0.68 for type B injuries and 0.72 for type C injuries, all representing substantial reliability. The lowest level of agreement for specific subtypes was for fracture subtype A4 (Kappa = 0.19). Intraobserver analysis demonstrated overall average Kappa statistic for subtype grading of 0.68 also representing substantial reproducibility. CONCLUSION: In a worldwide sample of spinal surgeons without previous exposure to the recently described AOSpine Thoracolumbar Spine Injury Classification System, we demonstrated moderate interobserver and substantial intraobserver reliability. These results suggest that most spine surgeons can reliably apply this system to spine trauma patients as or more reliably than previously described systems.

AOSpine subaxial cervical spine injury classification system.

PURPOSE: This project describes a morphology-based subaxial cervical spine traumatic injury classification system. Using the same approach as the thoracolumbar system, the goal was to develop a comprehensive yet simple classification system with high intra- and interobserver reliability to be used for clinical and research purposes. METHODS: A subaxial cervical spine injury classification system was developed using a consensus process among clinical experts. All investigators were required to successfully grade 10 cases to demonstrate comprehension of the system before grading 30 additional cases on two occasions, 1 month apart. Kappa coefficients (κ) were calculated for intraobserver and interobserver reliability. RESULTS: The classification system is based on three injury morphology types similar to the TL system: compression injuries (A), tension band injuries (B), and translational injuries (C), with additional descriptions for facet injuries, as well as patient-specific modifiers and neurologic status. Intraobserver and interobserver reliability was substantial for all injury subtypes (κ = 0.75 and 0.64, respectively). CONCLUSIONS: The AOSpine subaxial cervical spine injury classification system demonstrated substantial reliability in this initial assessment, and could be a valuable tool for communication, patient care and for research purposes.

The surgical algorithm for the AOSpine thoracolumbar spine injury classification system.

PURPOSE: The goal of the current study is to establish a surgical algorithm to accompany the AOSpine thoracolumbar spine injury classification system. METHODS: A survey was sent to AOSpine members from the six AO regions of the world, and surgeons were asked if a patient should undergo an initial trial of conservative management or if surgical management was warranted. The survey consisted of controversial injury patterns. Using the results of the survey, a surgical algorithm was developed. RESULTS: The AOSpine Trauma Knowledge forum defined that the injuries in which less than 30% of surgeons would recommend surgical intervention should undergo a trial of non-operative care, and injuries in which 70% of surgeons would recommend surgery should undergo surgical intervention. Using these thresholds, it was determined that injuries with a thoracolumbar AOSpine injury score (TL AOSIS) of three or less should undergo a trial of conservative treatment, and injuries with a TL AOSIS of more than five should undergo surgical intervention. Operative or non-operative treatment is acceptable for injuries with a TL AOSIS of four or five. CONCLUSION: The current algorithm uses a meaningful injury classification and worldwide surgeon input to determine the initial treatment recommendation for thoracolumbar injuries. This allows for a globally accepted surgical algorithm for the treatment of thoracolumbar trauma.

Considerations for assessing the potential effects of antidiabetes drugs on cardiac ventricular repolarization: A report from the Cardiac Safety Research Consortium.

Thorough QT studies conducted according to the International Council on Harmonisation E14 guideline are required for new nonantiarrhythmic drugs to assess the potential to prolong ventricular repolarization. Special considerations may be needed for conducting such studies with antidiabetes drugs as changes in blood glucose and other physiologic parameters affected by antidiabetes drugs may prolong the QT interval and thus confound QT/corrected QT assessments. This review discusses potential mechanisms for QT/corrected QT interval prolongation with antidiabetes drugs and offers practical considerations for assessing antidiabetes drugs in thorough QT studies. This article represents collaborative discussions among key stakeholders from academia, industry, and regulatory agencies participating in the Cardiac Safety Research Consortium. It does not represent regulatory policy.

Which Variables Are Associated With Patient-reported Outcomes After Discectomy? Review of SPORT Disc Herniation Studies.

BACKGROUND: The Spine Patient Outcomes Research Trial (SPORT) evaluated the effects of surgery versus nonoperative treatment for lumbar intervertebral disc herniation (IDH), among other pathologies. Multiple subgroup analyses have been completed since the initial publications, which have further defined which patient factors lead to better or worse patient-reported outcomes; however, the degree to which these factors influence patient-reported outcomes has not been explored. QUESTIONS/PURPOSES: We reviewed the subgroup analyses of the SPORT IDH studies to answer the following questions: (1) What factors predicted improvement in patient-reported outcomes after operative or nonoperative treatment of lumbar IDH? (2) What factors predicted worse patient-reported outcomes compared to baseline after operative or nonoperative treatment of lumbar IDH? And (3) what factors influenced patient-reported outcomes of surgery in patients with lumbar IDH? METHODS: We conducted a MEDLINE(®) search to identify the subgroup analyses of the SPORT IDH data that were responsive to our study questions. Eleven articles were identified that met our search criteria. RESULTS: The patient factors associated with larger improvements in Oswestry Disability Index at 4 years with either surgical or nonoperative treatment included a higher baseline Oswestry Disability Index, BMI of less than 30, not being depressed, being insured, having no litigation pending, not having workers compensation, and having symptoms for less than 6 weeks, though there were others. Factors leading to improvement with surgical treatment were mostly related to anatomic characteristics of the disc herniation such as posterolateral and sequestered herniations. There were no patient or clinical factors identified that were associated with worse patient-reported outcomes compared to baseline after either operative or nonoperative treatment. At 2-year followup, the treatment effects were greater for those patients with upper-level herniations, patients not receiving workers compensation, and nondiabetic patients. In a 4-year multivariate analysis, being married, without joint problems, and having worse symptoms at baseline resulted in greater treatment effect with surgery. CONCLUSIONS: While most patients with IDH will likely see improvement with either surgical or nonoperative treatment, there are patient-related factors that can help predict which subgroups will demonstrate a greater improvement with surgery, such as not having joint problems, being married, having worsening symptoms at baseline, and not having diabetes. These results can help providers and patients when discussing treatment options. LEVEL OF EVIDENCE: Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Variation in the management of thoracolumbar trauma and postoperative infection.

STUDY DESIGN: Multinational survey of spine trauma surgeons. OBJECTIVES: To survey spine trauma surgeons, examine the variety of management practices for thoracolumbar fractures, and investigate the need for future areas of study. BACKGROUND: Attempts to develop a universal thoracolumbar classification system represent the first step in standardizing treatment of thoracolumbar injuries, but there is little consensus regarding diagnosis and management of these injuries. METHODS: A survey questionnaire regarding a fictional neurologically intact patient with a burst fracture was administered to 46 spine surgeons. The questionnaire consisted of 2 domains: management of thoracolumbar fractures and management of postoperative infection. Survey results were compiled and evaluated and consensus arbitrarily assumed when the majority of surgeons agreed on a single question answer. RESULTS: Although majority consensus was reached on most questions, the interobserver reliability was poor. Consensus was achieved that magnetic resonance imaging should be performed during initial imaging. The majority would also operate regardless of magnetic resonance imaging findings, and would not operate at night. The favored technique was a posterior approach with decompression. Percutaneous fusion was considered a viable option by the majority of surgeons. No consensus was reached regarding instrumentation levels or construct length. The majority would use posterolateral bone grafting, and would not remove instrumentation nor perform an anterior reconstruction. Consensus was reached that postoperative bracing is unnecessary. Regarding management of infection, consensus was reached to use intraoperative vancomycin powder but not culture the nares before surgery. The majority used a set time period for antibiotic treatment when a drain was required, and would not apply supplementary bone graft at the time of final debridement and closure. CONCLUSIONS: There is lack of consensus regarding the appropriate management of thoracolumbar fractures. In the future, multicenter prospective studies are necessary to establish guidelines for the management of thoracolumbar fractures.

Safe zone for superolateral entry pin into the distal humerus in children: an MRI analysis.

BACKGROUND: The radial nerve is at risk for iatrogenic injury during placement of pins, screws, or wires around the distal humerus. Unlike adults, detailed anatomic information about the relationship of the nerve to the distal humerus is lacking in children. QUESTION/PURPOSES: This study evaluates the relationship of the radial nerve to the distal humerus in a pediatric population on conventional MRI and proposes an anatomic safe zone using easily identifiable bony landmarks on an AP elbow radiograph. METHODS: To determine the course of the radial nerve at the lateral distal humerus, we reviewed 23 elbow radiographs and MRIs of 22 children (mean age, 9 ± 4 years; range, 3-12 years) obtained as part of their workup for various elbow conditions. We described a technique using distance ratios calculated as a percentage of the patient's own transepicondylar distance, defined as the distance measured between the apices of the medial and lateral epicondyles, on the AP elbow radiograph and the midcoronal MR image. The cross-reference tool on a Picture Archiving and Communication System was then used to identify axial MR image at the level where the transepicondylar distance was measured. On this axial image, a line was drawn connecting the medial and lateral epicondyles (the transepicondylar axis) and its midpoint was determined. The radial nerve angle was measured by a line from the radial nerve to the midpoint of the transepicondylar axis and a line along the lateral half of the transepicondylar axis. On this axial slice, the closest distance from the nerve to the underlying cortex of the distal humerus was measured. To further localize the nerve along the distal humerus, predetermined percentages of the transepicondylar distance were projected proximally from the level of the transepicondylar axis along the longitudinal axis of the humerus on the midcoronal MR image. At these designated heights, the corresponding axial MR image was identified using the cross-reference tool and the nerve was mapped in a similar fashion. We then proposed a simpler method using a best-fit line drawn along the lateral supracondylar ridge on the AP radiograph to define the safe zone for lateral pin entry. RESULTS: On axial MR images, the radial nerve was located in the anterolateral quadrant with a mean radial nerve angle of 54° (range, 35°-87) at 0% transepicondylar distance (23 MRIs), 41° (range, 24°-63°) at 50% transepicondylar distance (23 MRIs), and ≥ 10° at 75% transepicondylar distance (on the 13 MRIs that extended this far cephalad). The mean closest distance between the radial nerve and the underlying humeral cortex was 10 mm (range, 3-26 mm) at 0% transepicondylar distance and 7 mm (3-16 mm) at 50% transepicondylar distance. On the AP elbow radiograph, the height of the lateral supracondylar ridge, determined by a best-fit line drawn along the lateral cortex of the ridge, diverged from the most proximal extent of the ridge at a point located at 60% transepicondylar distance (range, 51%-76%). At the corresponding location on the axial MR image, the nerve was located anterolaterally with a mean radial nerve angle of 39° (range, 15°-61°) and a mean distance of 6 mm (range, 2-10 mm) from the underlying humerus. CONCLUSIONS: Our data suggest that percutaneous direct lateral entry Kirschner wires and half-pins can be safely inserted in the distal humerus in children along the transepicondylar axis, either at or slightly posterior to the lateral supracondylar ridge, when placed caudal to the point located where the lateral supracondylar ridge line diverges from the proximal extent of the supracondylar ridge on AP elbow radiograph.

A sustainable training strategy for improving health care following a catastrophic radiological or nuclear incident.

The detonation of a nuclear device in a US city would be catastrophic. Enormous loss of life and injuries would characterize an incident with profound human, political, social, and economic implications. Nevertheless, most responders have not received sufficient training about ionizing radiation, principles of radiation safety, or managing, diagnosing, and treating radiation-related injuries and illnesses. Members throughout the health care delivery system, including medical first responders, hospital first receivers, and health care institution support personnel such as janitors, hospital administrators, and security personnel, lack radiation-related training. This lack of knowledge can lead to failure of these groups to respond appropriately after a nuclear detonation or other major radiation incident and limit the effectiveness of the medical response and recovery effort. Efficacy of the response can be improved by getting each group the information it needs to do its job. This paper proposes a sustainable training strategy for spreading curricula throughout the necessary communities. It classifies the members of the health care delivery system into four tiers and identifies tasks for each tier and the radiation-relevant knowledge needed to perform these tasks. By providing education through additional modules to existing training structures, connecting radioactive contamination control to daily professional practices, and augmenting these systems with just-in-time training, the strategy creates a sustainable mechanism for giving members of the health care community improved ability to respond during a radiological or nuclear crisis, reducing fatalities, mitigating injuries, and improving the resiliency of the community.

Lessons learned: medical and health care management for emergency workers at the TEPCO Fukushima Daiichi APP accident.

During the emergency work at the Fukushima Daiichi Atomic Power Plant (APP), the Tokyo Electric Power Company (TEPCO) and the Japanese government experienced various problems in medical and health care management issues, including special medical examinations, on-site triage and initial treatment, patient transportation, lodging and food, and long-term health care for emergency workers. To resolve these problems, the Ministry of Health, Labor and Welfare (MHLW) issued a series of compulsory directives and provided administrative guidance to TEPCO. Based on the experiences and lessons learned, the MHLW recognized that the proper management and implementation of medical and health care management in response to a similar accident would require sufficient measures and systematic preparation, including the following: 1. In case of large-scale nuclear accidents, the government needs to assist in dispatching medical staff to the affected plants. 2. Nuclear facility operators, medical facilities and fire departments should make an agreement to clarify the division of the roles played prior to the accident and should conduct emergency drills periodically with the full attendance of related personnel to identify and resolve the problems. 3. Operators need to develop a support base at a safe distance from the plant and to prepare to develop makeshift lodgings in case of emergency. 4. Operators need to come to an agreement to share food stocks among closely located nuclear plants and prepare cooking equipment that can be used in case of blackout to provide warm foods and drinks to as many workers as possible. 5. It is necessary to conduct long-term follow-up for emergency workers, including health care system, medical examinations and mental health consultations.

Impact of specialty and level of training on CT measurement of femoral version: an interobserver agreement analysis.

BACKGROUND: To determine the interobserver agreement on femoral version measurements between an orthopedic attending, orthopedic senior and junior residents, and an attending radiologist. MATERIALS AND METHODS: Postoperative computed tomography (CT) scanograms of 267 patients who underwent femoral intramedullary (IM) nailing with corresponding radiology attending reads for femoral version were collected and de-identified. Femoral version measurements performed by a trauma fellowship-trained attending orthopedic surgeon (ORTHO), a senior orthopedic resident (PGY4), a junior orthopedic resident (PGY1), and a musculoskeletal fellowship-trained attending radiologist (RADS) were compared via Pearson's interclass correlation coefficient to assess interobserver level of agreement. RESULTS: Version measurements provided by the two attending physicians exhibited the highest level of agreement (r = 0.661, p < 0.01). The orthopedic attending and the senior resident had the next highest level of agreement (r = 0.543, p < 0.01). The first-year orthopedic resident had the weakest agreement across the board: with the orthopedic attending, the radiology attending, and the senior resident. CONCLUSION: Regardless of specialty, experience and higher levels of training produce stronger agreement when measuring femoral version. Residents in training, especially those who are junior, produce weak agreement when compared to their senior colleagues. LEVEL OF EVIDENCE: Level III, diagnostic study.

A critical appraisal of Evicore's guidelines for advanced diagnostic imaging of the spine for lower extremity pain with neurological features.

Background: This analysis aims to evaluate the methodological quality of Evicore's spinal imaging guidelines for lower extremity pain with neurological features with or without lower back pain by leveraging the AGREE II tool. The AGREE II tool provides a framework to assess guideline development. It is well validated and has been used to evaluate many other guidelines previously. Methods: Five appraisers used the AGREE II appraisal tool to conduct a comprehensive review of Evicore's spinal imaging guidelines for lower extremity pain with neurological features. Appraisers provided an overall assessment of the guidelines as well as specific scores pertaining to domains including scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence. Results: Appraisers assigned numerical grades of 2, 2, 2, 3 and 4 (out of 7 total points, with 7 being the highest) for overall quality of the guidelines. Three appraisers recommended use of the guideline with modifications and two appraisers did not recommend the guideline. The AGREE II ratings had good reliability across the different raters [intraclass correlation coefficient (ICC) =0.881, 95% confidence interval (CI): 0.77, 0.94]. Conclusions: Evicore's guidelines would greatly benefit from increased identification and diversification of guideline development parties and stakeholders, increased rigor of development including a more robust discussion of the body of evidence and its strengths and limitations, and incorporation of more explicit suggestions for implementation of guideline recommendations by healthcare providers.

Nearly All Peer-to-Peer Reviews for CT and MRI Prior Authorization Denials for Orthopedic Specialists Are Approved.

In the event of prior authorization denial, physicians may request peer-to-peer review, which may delay treatment and increase administrative burden. The purpose of this study was to quantify the approval rate of peer-to-peer review and evaluate its efficiency in the context of advanced imaging use in an orthopedic practice. Patients at a single outpatient orthopedic clinic initially receiving an insurance denial for computed tomography or magnetic resonance imaging requiring peer-to-peer review from March to December 2022 were prospectively enrolled. Characteristics of the request, peer-to-peer review, and the reviewer and dates in the process were collected. If the study was approved after peer-to-peer review, the date of the imaging study and brief results were recorded. A total of 62 denials were included. One denial was approved prior to peer-to-peer review. Fifty-eight (of 61, 95.1%) reviews were approved, of which 51 (of 58, 87.9%) studies were completed by patients. Reviewers were always physicians (61 of 61, 100%), but of those whose specialty was known, none were orthopedic surgeons. Forty-four of 61 (72.1%) reviewers reported reviewing clinical notes in advance. The median number of days from visit to peer-to-peer review was 9.0 (interquartile range, 7.0-13.25). The median number of days from visit to imaging center appointment was 13.5 (interquartile range, 9.0-20.75) for approved studies. Of the 51 approved studies completed by patients, the results of 38 (74.5%) confirmed the suspected diagnosis. In an orthopedic specialty practice, almost all peer-to-peer reviews were approved, with the majority of the completed studies confirming the suspected diagnosis. Thus, patient care was delayed. Reform is crucial to improve the efficiency of the review process, especially in light of additional administrative and financial burden. [Orthopedics. 202x;4x(x):xx-xx.].

Stand-Alone Interbody Cage to Treat Cervical Facet Dislocation: A Case Report.

CASE: We present a 36-year-old man who sustained a traumatic C5-6 unilateral facet dislocation without neurological deficit. The patient was treated with anterior diskectomy and fusion using a stand-alone interbody cage. CONCLUSION: Current treatment of cervical facet dislocations (CFDs) in patients undergoing an anterior cervical diskectomy and fusion commonly makes use of plates with screw fixation and interbody grafts or cages to achieve spinal fusion after the diskectomy is performed. This report documents the successful treatment of a CFD with a stand-alone interbody cage.

Evaluating the Academic Influence of Orthopedic Surgeons in Spinal Literature Through Relative Citation Ratio.

INTRODUCTION:  The innovative iCite tool applies the relative citation ratio (RCR) to gauge the time and field-adjusted scientific influence of a publication. This study examines scholarly effects on spine surgery to distinguish the impact made by orthopedic surgeons, neurosurgeons, and several other specialists. MATERIALS AND METHODS:  From 2013 to 2017, 100 of the highest RCR-rated articles were gathered for each of the following terms: cervical disc herniation (CDH), lumbar disc herniation (LDH), lumbar spinal stenosis (LSS), neurogenic claudication (NC), radiculopathy (RAD), and sciatica (SC). The first, second, and last authors were queried for background and academic qualifications and placed into the following specialty categories: orthopedic surgery, neurosurgery, pain management, medicine, and others. To provide an alternative degree of influence, the Scopus database was employed to classify the h-index associated with each author. RESULTS:  Across the six search terms, there were 526 orthopedic surgeons among 1,730 authors (30.4%), with the highest representation in LSS (118/290, 40.7%), and the lowest in SC (45/286, 15.7%). Orthopedics was the most influential specialty across all six research terms by median RCR (p = 0.012). Compared to their neurosurgical counterparts, orthopedic authors had a greater influence in CDH (3.93 vs. 2.63, p = 0.0492), LDH (5.10 vs. 4.99, p = 1.0000), NC (2.16 vs. 1.40, p = 0.2370), and SC (3.35 vs. 3.04, p = 0.5285), but had a lower influence in LSS (5.13 vs. 5.32, p = 0.7736) and RAD (5.03 vs. 6.05, p = 0.3938). CONCLUSION:  Orthopedic surgeons lead other specialties when determining scholarly influence through RCR across six of the pre-designated research domains within spine surgery. For orthopedics, a modest influence in LSS and RAD may suggest potential areas of future focus. The use of bibliometrics to analyze available literature enables us to identify other specialties that have contributed to our field and promote interdisciplinary collaboration.

The Influence of Orthopedic Journals in Knee Arthritis Treatment Research: Evaluation Using Relative Citation Ratio.

Introduction The iCite database, developed by the National Institute of Health (NIH), utilizes a bibliometric known as the relative citation ratio (RCR) to gauge scholarly impact. The goal of this study was to use the RCR to evaluate the influence of orthopedic journals in regard to knee arthritis treatment literature, as no such studies exist to date. Materials and methods The 100 highest RCR-rated articles published between 2007 and 2017 were obtained in the following categories: physical therapy (PT), viscosupplementation (VS), nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroid injection (CSI), results of total knee arthroplasty (TKA), platelet-rich plasma (PRP), and meniscectomy (MS). Journals were categorized with respect to the following specialties: general orthopedics (GO), orthopedic subspecialty (OSS), nonsurgical musculoskeletal (NSMSK), general medicine (GM), and basic science/nonclinical (BS/NC). Results Across the seven domains, GO journals held the highest median RCR, while OSS ranked fourth (RCR, 6.60 versus 3.95; p=0.0027). GO journals were considered the most influential specialty in CSI (RCR, 2.99), while OSS journals held the highest median RCR in PRP (RCR, 4.10). OSS and GO journals ranked third (RCR, 4.79) and fourth (RCR, 4.21), respectively, in NSAIDs, lagging behind NSMSK and GM journals. Conclusions Bibliometric tools, such as the RCR, can inform the orthopedic field of current and future research trends and help guide further research efforts. Currently, publications in GO journals hold a strong influence in CSI but less so in PT and NSAIDs. The use of bibliometrics allows the identification of highly influential non-orthopedic articles and journals to read while identifying influential non-orthopedic researchers to promote interdisciplinary collaboration.

Factors Associated With Repeat Emergency Department Visits for Low Back Pain.

Background Low back pain represents 2-3% of Emergency Department (ED) visits. In this study, we aimed to identify patient and treatment-related variables that contributed to repeat visits to the ED for low back pain within a 12-month period. Methodology We conducted a retrospective review of adult patients presenting to the ED of one hospital over a two-year period with the primary diagnosis of low back pain. The primary outcome included return to the ED within 12 months with the same complaint, and the secondary outcome included return to the ED within 30 days or six months. Results A total of 793 patients met the inclusion criteria. The rate of return to the ED with the same complaint within 30 days, six months, and 12 months of the first visit was 7%, 11%, and 14%, respectively. Patients who received opioids at discharge were more likely to return within 12 months (68% vs. 55%; p = 0.0075) and six months (68% vs. 56%; p = 0.0184) compared to those who did not receive opioids at discharge. Undergoing an X-ray decreased the odds of a 30-day return visit by 70% (p = 0.0067), and by 59% within 12 months (p = 0.0032). Receiving opioids at discharge also doubled the odds of return within 12 months (odds ratio = 2.030, p = 0.0183), while receiving nonsteroidal anti-inflammatory drugs (NSAIDs) reduced the odds by 60% (p = 0.0028). Conclusions Patients who received opioids at discharge were more likely to have a return visit for low back pain within six and 12 months. Patients who underwent X-rays at the index visit and were prescribed NSAIDs at discharge were less likely to return to the ED for low back pain.