Agreement on fixation of pediatric supracondylar humerus fractures.

BACKGROUND: Pediatric supracondylar humerus fractures (pSCHFs) may be challenging injuries to treat because of the potential residual deformity. There is debate regarding the technical aspects of adequate closed reduction and crossed Kirschner wire (K-wire) fixation. PURPOSE: Do surgeons have an agreement on the aspects of the fixation of pSCHFs? METHODS: Radiographs of 20 patients from a cohort of 154 patients with pSCHFs treated with closed reduction and crossed K-wire fixation were selected. Forty-four surgeons viewed the postoperative radiographs and diagnosed the presence or absence of technical flaws and made a recommendation for or against reoperation. An expert panel of three orthopedic and trauma surgeons provided a reference standard for technical factors. Furthermore, final outcome 2 years after trauma was assessed. RESULTS: There was limited agreement on potential technical flaws (ICC 0.15-0.28), radiographic measures of alignment (ICC for anterior humeral line and Baumann angle of 0.37 and 0.23 respectively), the quality of postoperative reduction, position of the elbow in cast, and recommendation for repeat surgery (ICCs between 0.23 and 0.40). Sensitivity and specificity for these questions ranged from 0.59 to 0.90. There was no correlation between the voted quality of postoperative reduction and loss of reduction or final function. CONCLUSIONS: Surgeons have limited agreement on the quality of postoperative results in pSCHFs and the indication for reoperation. Reviewing postoperative radiographs may present a good learning opportunity and could help improve skills, but it is not a validated method for quality control and has to be seen in light of clinical outcome.

Patient and Clinician Perceptions about Remote Video Visits for Musculoskeletal Problems: A Qualitative Study.

BACKGROUND: An understanding of patient and clinician opinions about remote video musculoskeletal consultations might help determine how to increase appeal and utilization. The purpose of this study was to evaluate perceptions of remote video musculoskeletal consultations. Our research questions was what are patient and clinician facilitators and barriers for the use of remote video consultations? METHODS: Prior to the COVID-19 pandemic 27 English speaking adult patients seeking ambulatory care for a musculoskeletal problem, and 10 English-speaking musculoskeletal clinicians were interviewed using a guide. Interviews were audio-recorded, transcribed, and coded using applied thematic analysis. RESULTS: Patient and clinician incentives for remote video consultations included increased convenience, lower costs, less waiting time, and a better experience. Patient and clinician barriers to remote video consultations included concerns about familiarity with technology, lack of personal interaction and physical examination, inability to perform procedures, difficulties with reimbursement (clinicians), as well as technical, logistical, and privacy issues. CONCLUSION: This qualitative study performed prior to the pandemic found that adoption of remote video consultation for musculoskeletal problems may improve with seamless, efficient, and effective care, at an affordable price, particularly if the human connection is similar to what occurs in person.

Patient and clinician incentives and barriers for opioid use for musculoskeletal disorders a qualitative study on opioid use in musculoskeletal setting.

INTRODUCTION: Strategies for pain alleviation have relied heavily on opioids in the recent decades. One consequence is a crisis of opioid misuse, overdose, and overdose related death. This study sought patient and clinician incentives and barriers to the use of opioids in musculoskeletal illness. METHODS: In this qualitative study, twenty-eight patients and eight clinicians participated in a semi-structured interview seeking incentives and barriers for opioid use and prescription in musculoskeletal illness. Interviews were conducted by a trained qualitative interviewer. The interview data were transcribed and analyzed using a thematic analysis framework. RESULTS: Patient incentives for opioid use included doctor's orders, opioids being the only effective way to alleviate pain, alleviating symptoms of depression and anxiety, being able to keep a job, and lower cost of opioids relative to alternative treatment options. Patient barriers included associated risks (side effects, addiction) and wanting to control pain intensity. Clinician incentives for prescribing opioids included adequate pain alleviation, patient satisfaction, relatively inexpensive costs of opioids, convenience and doing what was taught by the clinician's superior. Lacking time and resources to adequately inform patients on appropriate opioid use and alternative treatments, likely results in more opioid prescribing than arguably necessary. Barriers for opioid prescribing included specific patient characteristics (psychiatric background, history of opioid misuse) and illness characteristics (nature of the injury, medical contra-indications). CONCLUSION: Patients feel that opioids should be used with caution. Clinicians in this study reported a tendency to default to opioids out of habit and convenience. Both patients and clinicians were aware that opioids are often misused to treat emotional pain.

Predictive value of cytokines for developing complications after polytrauma.

AIM: To investigate posttraumatic cytokine alterations and their value for predicting complications and mortality in polytraumatized patients. METHODS: Studies on the use of specific cytokines to predict the development of complications and mortality were identified in MEDLINE, EMBASE, Web of Science and the Cochrane Library. Of included studies, relevant data were extracted and study quality was scored. RESULTS: Forty-two studies published between 1988 and 2015 were identified, including 28 cohort studies and 14 "nested" case-control studies. Most studies investigated the cytokines interleukin (IL)-6, IL-8, IL-10 and tumor necrosis factor (TNF-α). IL-6 seems related to muliorgan dysfunction syndrome, multiorgan failure (MOF) and mortality; IL-8 appears altered in acute respiratory distress syndrome, MOF and mortality; IL-10 alterations seem to precede sepsis and MOF; and TNF-α seems related to MOF. CONCLUSION: Cytokine secretion patterns appear to be different for patients developing complications when compared to patients with uneventful posttraumatic course. More research is needed to strengthen the evidence for clinical relevance of these cytokines.