Evaluating Large Language Models in Extracting Cognitive Exam Dates and Scores.

Importance: Large language models (LLMs) are crucial for medical tasks. Ensuring their reliability is vital to avoid false results. Our study assesses two state-of-the-art LLMs (ChatGPT and LlaMA-2) for extracting clinical information, focusing on cognitive tests like MMSE and CDR. Objective: Evaluate ChatGPT and LlaMA-2 performance in extracting MMSE and CDR scores, including their associated dates. Methods: Our data consisted of 135,307 clinical notes (Jan 12th, 2010 to May 24th, 2023) mentioning MMSE, CDR, or MoCA. After applying inclusion criteria 34,465 notes remained, of which 765 underwent ChatGPT (GPT-4) and LlaMA-2, and 22 experts reviewed the responses. ChatGPT successfully extracted MMSE and CDR instances with dates from 742 notes. We used 20 notes for fine-tuning and training the reviewers. The remaining 722 were assigned to reviewers, with 309 each assigned to two reviewers simultaneously. Inter-rater-agreement (Fleiss' Kappa), precision, recall, true/false negative rates, and accuracy were calculated. Our study follows TRIPOD reporting guidelines for model validation. Results: For MMSE information extraction, ChatGPT (vs. LlaMA-2) achieved accuracy of 83% (vs. 66.4%), sensitivity of 89.7% (vs. 69.9%), true-negative rates of 96% (vs 60.0%), and precision of 82.7% (vs 62.2%). For CDR the results were lower overall, with accuracy of 87.1% (vs. 74.5%), sensitivity of 84.3% (vs. 39.7%), true-negative rates of 99.8% (98.4%), and precision of 48.3% (vs. 16.1%). We qualitatively evaluated the MMSE errors of ChatGPT and LlaMA-2 on double-reviewed notes. LlaMA-2 errors included 27 cases of total hallucination, 19 cases of reporting other scores instead of MMSE, 25 missed scores, and 23 cases of reporting only the wrong date. In comparison, ChatGPT's errors included only 3 cases of total hallucination, 17 cases of wrong test reported instead of MMSE, and 19 cases of reporting a wrong date. Conclusions: In this diagnostic/prognostic study of ChatGPT and LlaMA-2 for extracting cognitive exam dates and scores from clinical notes, ChatGPT exhibited high accuracy, with better performance compared to LlaMA-2. The use of LLMs could benefit dementia research and clinical care, by identifying eligible patients for treatments initialization or clinical trial enrollments. Rigorous evaluation of LLMs is crucial to understanding their capabilities and limitations.

Biomechanical Comparison of 3 Thumb Ulnar Collateral Ligament Repair Methods.

PURPOSE: Differences in range of motion, pinch strength, biomechanical strength, or joint angulation have previously been investigated for various means of treatment of ulnar collateral ligament (UCL) tears. We sought to address a gap in the literature by comparing thumb metacarpophalangeal (MCP) joint angle measurements and biomechanical strength before complete, acute UCL tear and after repair with suture anchors (SA), suture tape (ST) anchor augmentation, or reconstruction with palmaris longus graft (PL). METHODS: Thumbs and, if present, the PL tendon were harvested from 15 fresh-frozen cadavers. Each thumb specimen was secured into a servohydraulic biomechanical testing frame to evaluate native radiographic MCP joint angles at 0° flexion when loaded with 0, 5, and 13 N of radial force. Subsequently, a single hand surgeon (S.M.K.) performed complete transection and UCL repair via 1 of 3 methods: SA (n = 5), ST (n = 5), or reconstruction with PL (n = 5). Following repair, MCP joint angles were radiographically evaluated. Specimens that did not fail during joint angle testing were transferred to a separate testing frame for load-to-failure testing. Angle measurements and mean load-to-failure were compared between the groups, and angulation was also compared with each group's native control. RESULTS: Both ST and SA groups demonstrated comparable stiffness to their native controls, whereas the PL group was significantly more lax. The ST repair was significantly stiffer than the other constructs. ST also required higher forces to reach failure compared to both SA and PL. No difference was found between SA and PL groups. CONCLUSIONS: Although both ST and SA constructs recapitulate native joint stiffness, repair with ST demonstrated the greatest biomechanical strength in stiffness and load-to-failure. CLINICAL RELEVANCE: For complete, acute tears of the thumb UCL, ST may be superior for maintaining MCP joint stability and strength over SA and PL.

The Impact of Perceived Upper Extremity Severity and Prior Surgery on Patient-Reported Outcomes.

Background: The recently validated Hand Questionnaire (HAND-Q) is a multifaceted patient-reported outcome measure (PROM) for hand/upper extremity (UE) pathology and treatment. Here, we conduct a pilot study utilising data collected as a participating site for the Phase II HAND-Q Pilot Multicenter International Validation Study. We hypothesised that self-reported hand functionality, symptom/disease severity, hand appearance, emotional dissatisfaction and treatment satisfaction would be worse in patients who perceived their disease severity to be more severe but would not differ between patients based on prior surgical history. Methods: Patients were prospectively enrolled for HAND-Q participation from September 2018 to August 2019. Patients were included in this analysis if they responded to the following scales of HAND-Q: Hand Functionality Satisfaction, Symptom Severity, Hand Appearance Satisfaction, Emotional Dissatisfaction and Treatment Satisfaction. Composite scores (CS) were created for each section. Surgical versus non-surgical CS and mild versus moderate/severe CS were compared with t-tests. Bi-variate comparisons of responses were performed between surgical and non-surgical groups, and between mild and moderate/severe groups. Results: HAND-Q individual question analysis revealed significant differences in functionality and symptom severity for patients with prior surgery (p < 0.047). CS analysis confirmed greater overall impairment in surgical patients, but no overall impact on symptom severity. Regarding disease severity HAND-Q individual question analysis, moderate/severe patients reported worse outcomes for specific aesthetic qualities and symptoms for almost all items (p < 0.05). CS analysis revealed significantly worse overall hand appearance satisfaction, hand functionality, emotional satisfaction and symptom severity for patients with moderate/severe hand conditions. Conclusions: HAND-Q revealed worsened outcomes for UE patients with self-reported moderate/severe conditions or previous surgical history. Understanding how previous surgery and disease severity may impact clinical outcomes is important for crafting appropriate treatment. Level of Evidence: Level II (Prognostic Study).

Sexual Dissatisfaction after Hand Surgery.

Using the hand questionnaire (HAND-Q) patient-reported outcome measure, the effects of upper extremity surgery on patients' perception of their sex life were explored. The hand is a uniquely sexual organ, and we hypothesized that self-reported measures of disease severity, quality of life, and emotional impact would correlate with sexual dissatisfaction among patients receiving treatment for hand/upper extremity conditions. Methods: Patients were prospectively enrolled for hand questionnaire participation. Patients with valid responses to the following questions were included: functionality, hand appearance satisfaction, symptom severity, emotional dissatisfaction, sexual dissatisfaction, and treatment satisfaction. Composite scores were created and scored. Sexual dissatisfaction composite scores were compared through Spearman correlation coefficient analysis to quality of life, emotional dissatisfaction, hand appearance, symptom severity, and hand functionality. Results: High levels of diminished quality of life correlated with sexual dissatisfaction (rs = 0.748, P < 0.001). Increased emotional dissatisfaction correlated with sexual dissatisfaction (rs = 0.827, P < 0.001). Increased satisfaction with hand appearance negatively correlated with sexual dissatisfaction (rs = -0.648, P = 0.001). Increased levels of dissatisfaction with hand functionality correlated with sexual dissatisfaction (rs = 0.526, P = 0.005). Conclusions: The correlation between sex life and quality of life may allow surgeons to improve patient satisfaction when treating hand/upper extremity issues. The relationship between sex life and emotional dissatisfaction emphasizes the impact that sexual dissatisfaction has on patients' lives. Evaluating the relationship between hand appearance and sexual dissatisfaction may indicate that patient self-perception of hand attractiveness plays a role in sex life.

WALANT Hand and Upper Extremity Procedures Performed With Minor Field Sterility Are Associated With Low Infection Rates.

Background: The use of minor field sterility in hand/upper extremity cases has been shown to improve workflow efficiency while maintaining patient safety. As this finding has been limited to specific procedures, we investigated the safety of performing a wide array of hand/upper extremity procedures outside the main operating room using minimal field sterility with Wide-Awake Local Anaesthesia No Tourniquet (WALANT) anaesthesia by evaluating superficial and deep infection rates across a diverse series of cases. Methods: This study was a case series conducted between October 2017 and June 2020. Of all, 217 patients underwent hand/upper extremity procedures performed in a minor procedure room via WALANT technique with field sterility. Primary outcome measures include superficial and deep surgical site infections within 14 days post-surgery. Results: Of all, 217 patients were included in this study; 265 consecutive hand/upper extremity operations were performed by a single surgeon, with notable case diversity. The majority of patients (n = 215, 99.1%) did not report or present with signs of infection before or after their operation. We report 0% 14-day and 0.37% 30-day surgical site infection rates for such hand/upper extremity procedures performed in a minor procedure room with field sterility. Conclusion: Hand/upper extremity procedures performed via WALANT technique with field sterility in a minor procedure room are associated with low surgical site infection rates. These rates are comparable to surgical site infection rates for similar surgeries performed in main operating rooms with standard sterilization procedures. Thus, the implementation of this technique may allow for improved workflow efficiency and reduced waste, all while maintaining patient safety.

Historique: Il est démontré que le recours à un champ stérile mineur dans les interventions de la main et des extrémités supérieures améliore le déroulement du travail tout en maintenant la sécurité du patient. Comme cette observation se limite à des interventions particulières, les chercheurs ont examiné la sécurité d'un large éventail d'interventions de la main et des extrémités supérieures au moyen de la technique d'anesthésie de WALANT (acronyme anglais d'anesthésie locale en plein éveil sans tourniquet) hors de la salle d'opération principale. Pour ce faire, ils ont évalué le taux d'infections superficielles et profondes dans une série de cas variés. Méthodologie: La présente série de cas a été réalisée entre octobre 2017 et juin 2020. Au total, 217 patients ont subi une intervention mineure de la main ou des extrémités supérieures exécutée dans une salle d'intervention mineure sur champ stérile au moyen de la technique d'anesthésie de WALANT. Les mesures de résultat primaire incluaient des infections superficielles et profondes au foyer chirurgical dans les 14 jours suivant l'intervention. Résultats: Au total, 217 patients ont participé à l'étude. Un seul chirurgien a effectué 265 opérations consécutives de la main ou des extrémités supérieures, d'une diversité remarquable. La majorité des patients (n = 215, 99,1 %) n'ont pas déclaré ni présenté de signes d'infection avant ou après leur opération. Les chercheurs ont déclaré un taux d'infection de 0 % au foyer chirurgical au bout de 14 jours et de 0,37 % au bout de 30 jours pour les interventions de la main et des extrémités exécutées sur champ stérile dans une salle d'intervention mineure. Conclusion: Les interventions de la main et des extrémités supérieures exécutées sur champ stérile par la technique d'anesthésie de WALANT dans une salle d'intervention mineure sont liées à un faible taux d'infection au foyer chirurgical. Ces taux sont comparables à ceux des infections au foyer chirurgical lors d'interventions semblables exécutées dans une salle d'opération principale dotée d'interventions de stérilisation standard. Ainsi, la mise en œuvre de cette technique pourrait améliorer le déroulement du travail et réduire le gaspillage, tout en maintenant la sécurité du patient.

The 100 Most Impactful Papers in Hand and Upper Extremity Surgery over the Last 25 Years: A Bibliometric Analysis of the Orthopaedic Literature.

Introduction Despite growth in hand/upper extremity investigation, impactful studies have not been thoroughly identified. Previous studies have been limited in scope. This study sought to identify and characterize the most impactful orthopaedic papers in hand/upper extremity over the past 25 years. Materials and Methods The top 1,000 hand/upper extremity orthopaedic studies published from 1992 to 2017 were identified with Web of Science. After screening for relevance in order of decreasing citation number, the top 100 articles were identified for bibliometric analysis. Results The mean number of authors and citations were 4.51 (range, 1-21) and 169.4 (range, 105-863). Common study types included, case series ( n = 52), randomized controlled trial ( n = 17), and prospective cohort ( n = 16), which predominantly covered topics related to shoulder ( n = 34), wrist/forearm ( n = 21), and hand ( n = 17). Among wrist/forearm and hand studies, distal radius fractures ( n = 12) and nerve-related topics ( n = 10) were most frequently analyzed. Most studies were of level IV ( n = 51) and level II ( n = 16) evidence. Recent studies had greater impact (mean citations/year: 2011, 82.7/year vs. 1992, 16.1/year). Conclusion Most of the 100 top orthopaedic articles in hand/upper extremity were of level IV or II evidence, retrospective, and nonrandomized. Despite an observed recent increase in level I studies, a lack of prospective, randomized trials is apparent.

WALANT Hand Surgery: Do the AORN Guidelines Apply?

This study evaluates current guidelines for patients receiving local anesthesia, set forth by the Association of Perioperative Nurses (AORN), within the context of hand surgery. The study reviewed 217 patients and 265 operations performed under wide-awake local anesthesia no tourniquet (WALANT) technique in an outpatient procedure room with minor field sterility. Only the surgeon, one resident, and one circulating nurse were present. All surgical complications were documented, including any infection at postoperative follow-ups. One female patient developed a deep surgical site infection (SSI) following repair of her flexor digitorum superficialis and flexor digitorum profundus, which resolved after irrigation/debridement. We report 0% intraprocedural complication, 0% superficial SSI, and 0.37% deep SSI (n = 1) incidence across this cohort. Most institutions require two nurses present for local anesthesia, but our low complication and infection incidence suggest a single circulating nurse present during WALANT hand surgeries may improve nurse staffing, drive greater turnover efficiency, and reduce costs. (Journal of Surgical Orthopaedic Advances 30(3):156-160, 2021).

WALANT Hand Surgery Does Not Require Postoperative Opioid Pain Management.

BACKGROUND: Currently, opioids are the standard of care for postoperative pain management. Avoiding unnecessary opioid exposure in patients is of current interest because of widespread abuse. METHODS: This is a prospective cohort study in which wide-awake, local anesthesia, no-tourniquet (WALANT) technique was used for 94 hand/upper extremity surgical patients and compared to patient cohorts undergoing similar procedures under monitored anesthesia care. Patients were not prescribed opioids postoperatively but were instead directed to use over-the-counter pain relievers. Pain scores on a visual analogue scale were collected from patients preoperatively, and on postoperative days 1 and 14. WALANT visual analogue scale scores were compared to those of the two patient cohorts who either did or did not receive postoperative opioids after undergoing similar procedures under monitored anesthesia care. Electronic medical records and New York State's prescription monitoring program, Internet System for Tracking Over-Prescribing, were used to assess prescription opioid-seeking. Information on sex, age, comorbidity burden, previous opioid exposure, and insurance coverage was also collected. RESULTS: Decreased pain was reported by WALANT patients 14 days postoperatively compared to preoperatively and 1 day postoperatively, with a total group mean pain score of 0.37. This is lower than mean scores of monitored anesthesia care patients with and without postoperative opioids. Only two WALANT patients (2.1 percent) sought opioid prescriptions from outside providers. There was little evidence suggesting factors including sex, age, comorbidity burden, previous opioid exposure, or insurance status alter these results. CONCLUSION: WALANT may be a beneficial technique hand surgeons may adopt to mitigate use of postoperative opioids and reduce risk of abuse in patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Increases in Firework-Related Upper Extremity Injuries Correspond to Increasing Firework Sales: An Analysis of 41,195 Injuries Across 10 Years.

INTRODUCTION: Between 2008 and 2017, the American Pyrotechnics Association reported a 41% increase in revenue from firework sales, with 2017 showing $885 million US dollars in consumer sales. We sought to evaluate the epidemiology of firework-related upper extremity injuries during this 10-year period, hypothesizing that hand/upper extremity injuries from fireworks were increasing in the United States. METHODS: Observational epidemiologic assessment of a weighted cohort of patients via the National Electronic Injury Surveillance System from 2008 to 2017. The National Electronic Injury Surveillance System provides a nationwide probability sample of injuries related to consumer products based on emergency department visits collected from a cohort of about 100 US hospitals. RESULTS: A total of 1,079 patients representing an estimated 41,195 firework-related upper extremity injuries presented to US emergency departments from 2008 to 2017. The number of injuries increased significantly from 2,576 in 2008 to 5,101 in 2017 (R2 = 0.85, R = 0.92, P < 0.001). A Spearman rank-order correlation determined that there was a strong, positive correlation between the increase in firework sales and the increase in injuries (rs = 0.939, P < 0.01). The overwhelming majority of firework-related injuries were seen in males (77%) aged 11 to 29 years (48%). The hand and fingers accounted for 85.8% of injuries, with the thumb being the most commonly injured body part (51.3%). Burns were the most common injury across all body sites except the wrist, where fractures were most common. CONCLUSION: Ten-year firework-related upper extremity injuries increased, corresponding to increased consumer sales across the same period. This study provides previously absent population-level data to provide a framework for discussion among policy makers and physicians alike in an attempt to mitigate the use of fireworks and their associated upper extremity injuries. LEVEL OF EVIDENCE: Level III.

Outcomes of an aseptic technique for Kirschner wire percutaneous pinning in the hand and wrist.

INTRODUCTION: Kirschner wires (K-wires) have been shown to effectively stabilize fractures of the hand and wrist, but are associated with high infection rates, which may limit its use. Previous literature has attributed the risk of infection to many different aspects of a fixation technique. However, we introduce an approach to percutaneous K-wire pinning to mitigate the risk of infection. METHODS: Patients undergoing K-wire fixation procedures of the hand and wrist were retrospectively queried. All cases were performed under the same principles of our technique. None of the K-wires were buried, nor bent and were covered with betadine-soaked alcohol pads as pin site dressings. Pins were removed in an outpatient procedure room up to 12 weeks postoperatively and were then assessed for signs of superficial or deep infection. RESULTS: 90 patients were included in this study across a variety of K-wire fixation operations in the hand and wrist. No patients presented with any signs of infection or other complications necessitating postoperative antibiotics, early pin removal, or reoperation. DISCUSSION/CONCLUSION: The specific guidelines of our technique resulted in no cases of pin site infection, despite a largely underserved patient population. Our low incidence of infection was maintained without the use of prophylactic antibiotics and in patients with long periods of fixation. While the high infection rates in previous literature have often been associated with wires left exposed, the principles of our technique allow for K-wire fixations to be performed percutaneously without burying the wires. This may allow for improved cost and time efficiency, without compromising patient safety.

Effect of Collagen Nerve Wrapping in a Rabbit Peripheral Neuropathy Model.

BACKGROUND: Collagen nerve wraps (CNWs) theoretically allow for improved nerve gliding and decreased perineural scarring, and create a secluded environment to allow for nerve myelination and axonal healing. The goal of this study was to investigate the effect of CNWs on nerve gliding as assessed by pull-out strength and nerve changes in a rabbit model of peripheral neuropathy. METHODS: Ten New Zealand rabbits were included. Sham surgery (control) was performed on left hindlimbs. To simulate compressive neuropathy, right sciatic nerves were freed of the mesoneurium, and the epineurium was sutured to the wound bed. Five rabbits were euthanized at 6 weeks [scarred nerve (SN); n = 5]. Neurolysis with CNW was performed in the remaining rabbits at 6 weeks (CNW; n = 5), which were euthanized at 22 weeks. Outcomes included peak pull-out force and histopathological markers of nerve recovery (axonal and Schwann cell counts). RESULTS: The CNW group demonstrated significantly higher pull-out forces compared with the CNW sham control group (median: 4.40N versus 0.37N, P = 0.043) and a trend toward greater peak pull-out forces compared with the SN group (median: 4.40N versus 2.01N, P = 0.076). The CNW group had a significantly higher median Schwann cell density compared with the CNW control group (CNW: 1.30 × 10-3 cells/µm2 versus CNW control: 7.781 × 10-4 cells/µm2, P = 0.0431) and SN group (CNW: 1.30 × 10-3 cells/µm2 versus SN: 7.31 × 10-4 cells/µm2, P = 0.009). No significant difference in axonal density was observed between groups. CONCLUSION: Our findings suggest using a CNW does not improve nerve gliding, but may instead play a role in recruiting and/or supporting Schwann cells and their proliferation.