Odds of Attaining Orthopaedic Leadership Based on Race, Ethnicity, and Sex.

BACKGROUND: Despite widespread acceptance of the importance of diversity in leadership, systemic challenges in leadership attainment in orthopaedic surgery still exist for several groups. We hypothesize that women, underrepresented in medicine groups, and Asians have decreased odds of achieving program director and chairperson positions compared with peers. METHODS: Demographic data were collected from the Association of American Medical Colleges for faculty, program directors, and chairpersons in orthopaedic surgery. Odds ratios were calculated treating race, ethnicity, or sex as the predictor variables and attainment of a leadership position as the outcome, comparing the composition of program directors in 2020 and chairpersons in 2019 with faculty in 2019. RESULTS: Significantly decreased odds were found for women at 0.37 (0.264 to 0.51 [P < 0.0001]) and the Other category at 0.16 (0.065 to 0.3864 [P = 0.0001]) while significantly increased odds were found for White and Black/African American faculty at 1.32 (1.02 to 1.71 [P = 0.0314]) and 1.95 (1.17 to 3.26 [P = 0.011]), respectively, in holding program director positions. Significantly decreased odds of attaining chairpersonship were found for women at 0.17 (0.07 to 0.41 [P = 0.0075]) and Asian faculty at 0.33 (0.14 to 0.75 [P = 0.0062]) while White faculty demonstrated significantly increased odds at 2.43 (1.41 to 4.19 [P = 0.0013]). CONCLUSIONS: Women showed markedly decreased odds of leadership attainment while Black/African American faculty had increased likelihood of becoming program directors but were not markedly more likely to become chairs. Asian faculty were less likely to become program directors and markedly less likely to become chairs. While decreased odds for women were expected based on current literature, decreased odds of Asians becoming chairs and an increased likelihood of Black/African American orthopaedic surgeons becoming program directors but not attaining the role of chairs at the same rate were novel findings, revealing concerning trends for these groups.

Cutibacterium acnes Infection as a Cause of Nonunion After Ulnar-Shortening Osteotomy.

Ulnar-shortening osteotomy is a reliable solution to treat ulnar impaction syndrome, but it has a significant rate of nonunion as a known complication. Generally nonunion after the procedure is attributed to noninfectious causes. When infections happen, they follow the microbiological trends of nonunions elsewhere in the body. We present a case of ulnar-shortening osteotomy using an oblique-cut osteotomy system that resulted in septic nonunion. At the time of revision surgery, Cutibacterium acnes and Staphylococcus hominis were isolated from the osteotomy site. The patient was successfully treated using intravenous antibiotics and the two-stage Masquelet technique and eventually went on to bony union. As C acnes is rarely encountered in this context, this report highlights the need to consider all possible pathogens in the workup of a potentially septic nonunion. Surgeons should consider bacteria such as C acnes that require prolonged incubation for isolation from cultures, which may not be part of many institutions' usual protocol. [Orthopedics. 2024;47(4):e211-e213.].

H3F3A K27M Mutations Drives a Repressive Transcriptome by Modulating Chromatin Accessibility, Independent of H3K27me3 in Diffuse Midline Glioma.

Background: Heterozygous histone H3.3K27M mutation is a primary oncogenic driver of Diffuse Midline Glioma (DMG). H3.3K27M inhibits the Polycomb Repressive Complex 2 (PRC2) methyltransferase complex, leading to a global reduction and redistributing of the repressive H3 lysine 27 tri-methylation. This rewiring of the epigenome is thought to promote gliomagenesis. Methods: We established novel, isogenic DMG patient-derived cell lines that have been CRISPR-Cas9 edited to H3.3 WT or H3.3K27M alone and in combination with EZH2 and EZH1 co-deletion, inactivating PRC2 methyltransferase activity of PRC2 and eliminating H3K27me3. Results: RNA-seq and ATAC-seq analysis of these cells revealed that K27M has a novel epigenetic effect that appears entirely independent of its effects on PRC2 function. While the loss of the PRC2 complex led to a systemic induction of gene expression (including HOX gene clusters) and upregulation of biological pathways, K27M led to a balanced gene deregulation but having an overall repressive effect on the biological pathways. Importantly, the genes uniquely deregulated by the K27M mutation, independent of methylation loss, are closely associated with changes in chromatin accessibility, with upregulated genes becoming more accessible. Notably, the PRC2- independent function of K27M appears necessary for tumorigenesis as xenografts of our H3.3K27M/EZH1/2 WT cells developed into tumors, while H3.3/EZH1/2 KO cells did not. Conclusion: We demonstrate that K27M mutation alters chromatin accessibility and uniquely deregulates genes, independent of K27 methylation. We further show the mutation's role in altering biological pathways and its necessity for tumor development. Key Points: We revealed genes regulated by H3.3K27M mutation and PRC2 in DMG.H3.3K27M mutation alters chromosome accessibility independent of H3K27me3.PRC2-independent effects of K27M mutation are crucial for tumor development. Importance of the Study: This study is the first to demonstrate that H3F3A K27M mutations drive a repressive transcriptome by modulating chromatin accessibility independently of H3K27 trimethylation in Diffuse Midline Glioma (DMG). By isolating the effects of H3.3 K27me3 loss from those of the K27M mutation, we identified common and unique genes and pathways affected by each. We found that genes uniquely deregulated by K27M showed increased chromatin accessibility and upregulated gene expression, unlike other gene subsets affected by PRC2 knockout. Importantly, we determined the PRC2-independent function of K27M is also essential for tumorigenesis, as xenografts of H3.3 K27M/PRC2 WT cell lines formed tumors, while H3.3WT/PRC2 WT and K27M/PRC2 knockout cells did not. This research builds upon and advances prior studies, such as those identifying EZH2 as a therapeutic target in H3.3K27M DMGs, by revealing critical new pathways for gliomagenesis. The translational significance lies in identifying novel therapeutic targets against this aggressive pediatric cancer.

How Did Black and Hispanic Orthopaedic Applicants and Residents Compare to General Surgery Between 2015 and 2022?

BACKGROUND: Despite the heavy demand for and knowledge of the benefits of diversity, there is a persistent lack of racial, ethnic, and gender diversity in orthopaedic surgery. Since the implementation of diversity initiatives, data have shown that general surgery has been one of the top competitive surgical fields and has demonstrated growth in racial, ethnic, and gender diversity, making general surgery a good point of reference and comparison when analyzing racial and ethnic growth in orthopaedic surgery. QUESTIONS/PURPOSES: (1) What were the growth rates for Black and Hispanic orthopaedic residency applicants and residents between 2015 and 2022? (2) How did the growth rates of Black and Hispanic individuals in orthopaedic surgery compare with those of general surgery? (3) How did applicant recruitment and resident acceptance differ between Black and Hispanic people in orthopaedic surgery? METHODS: Applicant data were obtained from historical specialty-specific data from the Association of American Medical Colleges Electronic Residency Application Service Statistics database between 2018 and 2022, and resident data were obtained from the Accreditation Council of Graduate Medical Education Data Resource Book between 2015 and 2021. Between 2018 and 2022, the number of residency applicants totaled 216,677, with 17,912 Black residency applicants and 20,413 Hispanic residency applicants. Between 2015 and 2021, the number of active residents totaled 977,877, with 48,600 Black residents and 62,605 Hispanic residents. Because the applicant and resident data do not overlap throughout all years of observation, a sensitivity analysis of overlapping years (between 2018 and 2021) was conducted to ensure observed trends were consistent and valid throughout the study. All datasets obtained were used to establish the different racial and ethnic proportions of Black and Hispanic residency applicants and residents in four nonsurgical primary care specialties and four surgical subspecialties. A reference slope was created using data from the Association of American Medical Colleges and Accreditation Council of Graduate Medical Education to represent the growth rate for total residency applicants and residents, independently, across all residency specialties reported in each database. This slope was used for comparison among the resident and applicant growth rates for all eight selected specialties. Datapoints were placed into a scatterplot with regression lines, using slope equations to depict rate of growth and R 2 values to depict linear fit. Applicant growth corresponded to applicant recruitment and resident growth corresponded to resident acceptance. Chi-square tests were used to compare residents and residency applicants for the Black and Hispanic populations, separately. Two-way analysis of variance with a time-by-specialty interaction term (F-test) was conducted to determine differences between growth slopes. RESULTS: There was no difference in the growth rate of Black orthopaedic surgery applicants between 2018 and 2022, and there was no difference in the growth rate of Hispanic orthopaedic surgery applicants (R 2 = 0.43; p = 0.23 and R 2 = 0.63; p = 0.11, respectively). However, there was a very slight increase in the growth rate of Black orthopaedic surgery residents between 2015 and 2021, and a very slight increase in the growth rate of Hispanic orthopaedic surgery residents (R 2 = 0.73; p = 0.02 and R 2 = 0.79; p = 0.01, respectively). There were no differences in orthopaedic and general surgery rates of growth for Black applicants between 2018 and 2022 (0.004 applicants/year versus -0.001 applicants/year; p = 0.22), and no differences were found in orthopaedic and general surgery rates of growth for Black residents between 2015 and 2021 (0.003 residents/year versus 0.002 residents/year; p = 0.59). Likewise, Hispanic orthopaedic applicant growth rates did not differ between 2018 and 2022 from the rates of general surgery (0.004 applicants/year versus 0.005 applicants/year; p = 0.68), and there were no differences in orthopaedic and general surgery rates of growth for Hispanic residents (0.007 residents/year versus 0.01 residents/year; p = 0.35). Furthermore, growth rate comparisons between Black orthopaedic applicants and residents between 2018 and 2021 showed applicant growth was larger than resident growth, illustrating that the recruitment of Black applicants increased slightly more rapidly than resident acceptance. Growth rate comparisons between Hispanic applicants and residents showed a larger rate of resident growth, illustrating Hispanic resident acceptance increased slightly faster than applicant recruitment during that time. CONCLUSION: We found low acceptance of Black residents compared with the higher recruitment of Black applicants, as well as overall low proportions of Black and Hispanic applicants and residents. Future studies might explore the factors contributing to the higher acceptances of Hispanic orthopaedic residents than Black orthopaedic residents. CLINICAL RELEVANCE: We recommend that more emphasis should be placed on increasing Black and Hispanic representation at the department level to ensure cultural considerations remain at the forefront of applicant recruitment. Internal or external reviews of residency selection processes should be considered, and more immersive, longitudinal orthopaedic surgery clerkships and research mentorship experiences should be targeted toward Black and Hispanic students. Holistic reviews of applications and selection processes should be implemented to produce an increased racially and ethnically diverse applicant pool and a diverse residency work force, and implicit bias training should be implemented to address potential biases and diversity barriers that are present in residency programs and leadership.

The Impact of Experience Versus Decision Aids on Patient Preference Toward Virtual Care.

Introduction: Virtual care utilization has increased in recent years bringing questions of how to best inform patients regarding their use. Decision aids (DAs) are tools created to assist patients in making informed decisions about their health care. This study seeks to determine whether a DA or previous experience could better educate and influence patient's preference on virtual care. Methods: One hundred fifty participants from an orthopedic clinic of a multi-hospital system were divided into three groups. Group 1 (Virtual Care Cohort) had at least one previous virtual care visit and was surveyed with the Telemedicine Satisfaction Questionnaire (TSQ). Group 2 (In-person with Decision Aid) and Group 3 (In-person without Decision Aid) had no virtual care experience. Group 2 received a validated virtual care DA with a knowledge test. Both groups were also administered the TSQ. Results: After the DA, patients improved their score on 3 of 4 virtual care knowledge questions. Each cohort demonstrated a positive perception of virtual care; however, the specific reasons for their favorable views varied. The DA cohort did not show increased preference toward virtual care compared with the non-DA group and only responded significantly higher regarding encounter comfort. Patients with previous experience in virtual care responded most favorably to the majority of survey questions regarding their virtual care preferences when compared with both virtual care naive cohorts. Discussion and Conclusion: We found that patient experience was the most important factor in influencing patient preference toward virtual care. Although the DA increased their virtual care knowledge it did not increase their preference; therefore, efforts should be placed at encouraging patient to experience virtual care.

Orthopaedic Hand Patient Support Systems Have Valuable Insight to Patient Function and Pain.

Patient-reported outcome measures (PROs) are increasingly used in clinical assessment. Research on how patient support systems contribute to physician understanding of patient condition is limited. Thus, insights from significant others may provide value, especially when concerns exist regarding patient response validity. Patients recruited from the pre-operative environment undergoing orthopaedic hand procedures responded to PROMIS-Pain Interference (PI), PROMIS-Upper Extremity (UE), PROMIS-Depression (D), and QuickDASH. They then selected a significant other (SO) to do the same. Patients and SOs were also asked to complete the West Haven-Yale Multidimensional Pain Inventory (WHYMPI) as a measure of support-related responses. Patient and SO responses were compared, and support-related responses were added in subsequent analyses to examine their effect on SO PRO assessment.

Patients With and Without Double Crush Syndrome Achieve Similar Rates of Clinical Improvement Following Carpal Tunnel Release.

BACKGROUND: The purpose of this study is to compare outcomes of carpal tunnel release (CTR) in patients with and without double crush syndrome (DCS), defined as concurrent carpal tunnel syndrome (CTS) and cervical radiculopathy at C5-T1 on preoperative nerve conduction studies. METHODS: Patients with preoperative nerve conduction studies who underwent unilateral, isolated CTR were retrospectively identified. All patients completed preoperative and 3-month postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) and pain interference (PI), and Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaires, and responded to the anchor question: "Since your treatment, how would you rate your overall function?" (much worse, worse, slightly worse, no change, slightly improved, improved, much improved). Preoperative, postoperative, and changes in scores for UE, PI, and QuickDASH were compared, as were the anchor question responses and rates of achieving the minimal clinically important difference (MCID). RESULTS: Sixty-three patients with DCS and 115 patients with CTS only were included. At 3- to 4-month follow-up, absolute and change in UE, PI, and QuickDASH scores were not statistically different between patients with DCS and CTS. Rates of anchor question response and MCID achievement were comparable for patients with CTS only and DCS on each questionnaire. The MCID achievement ranged from 48.4% to 68.8% in the unmatched cohort and 48.4% to 60% in the matched group. CONCLUSIONS: At 3 to 4 months, patients with DCS experience similar patient-reported symptomatic and functional improvement, and achieve MCID of outcome measures at comparable rates to patients with CTS only. For patients with nerve compression at the carpal tunnel and cervical spine, CTR is a reasonable first step prior to proceeding with cervical spine decompression.

Revenue Generation and Follow-up for a Hand Trauma Program for Emergency Department Patients in an Inner-City Metropolitan Area.

BACKGROUND: Although hand trauma care has proved to be profitable, loss of trauma patients from a system may lead to revenue loss. Our study aimed to (1) elucidate the economic effect of hand trauma programs, (2) quantify the potential fiscal effect of loss of follow-up, and (3) determine factors contributing to leakage of patients from the healthcare system. METHODS: Revenue data were retrospectively extracted for all adult hand trauma patients within a multicenter healthcare system from 2014 to 2018. Demographic and encounter factors were analyzed using Wilcoxon rank-sum test for differences in continuous variables, Pearson chi square test for categorical variables, and odds ratios. A follow-up model was created using logistic regression. RESULTS: A total of 56,995 (31% new, 69% established) hand trauma encounters were recorded. Follow-up was markedly affected by many factors, including new vs. established patients. Of the 17,748 new patients, 8638 (48.6%) returned for subsequent care, generating $34M. The patients who did not return may have lost $176M for the system. CONCLUSIONS: Many factors lead to loss of follow-up. Understanding these factors can help target efforts to minimize leakage of hand trauma patients. Hand trauma introduces new patients to hospitals, generating notable revenue. Leakage of hand trauma patients has substantial revenue losses.

Racial, Ethnic, and Sex Diversity in Academic Medical Leadership.

Importance: For the past 50 years, significant gaps have existed in gender and racial diversity across various medical specialties, despite the many benefits of a diverse physician workforce. One proposed approach to increasing diversity is top-down diversification, in which diverse leadership results in increased minority and female workforce representation. Objective: To investigate the changes in academic medical leadership diversity from 2007 to 2019 and to assess the recent leadership diversity of various specialties compared with the averages across all specialties. Design, Setting, and Participants: This was a cross-sectional analysis of physicians in varying academic roles in 2007, 2019, and 2020. Demographic data were collected via specialized reports from the Association of American Medical Colleges. Included were 4 primary care specialties (internal medicine, family medicine, pediatrics, obstetrics/gynecology [OB/GYN] and 4 surgical specialties (orthopedic surgery, neurologic surgery, otolaryngology [ENT], general surgery). Study participants were faculty, program directors, and chairpersons. Data were analyzed for the years 2007, 2019, and 2020. Intervention: Self-reporting of demographic information to residency programs collected via the Graduate Medical Education Track Survey. Main Outcomes and Measures: Proportions of each race/ethnicity and sex among cohorts of participants and comparisons between them. Results: The total number of individuals investigated included 186 210 faculty from 2019 (79 441 female [42.7%]), 6417 program directors from 2020 (2392 female [37.3%]), 1016 chairpersons from 2007 (89 female [8.8%]), and 2424 chairpersons from 2019 (435 female [17.9%]). When comparing chairperson diversity from 2007 to 2019, only internal medicine and general surgery experienced significant increases in minority (aggregate category used throughout the investigation to refer to anyone who self-identified as anything other than non-Hispanic White) representation (90% increase [11.7 percentage points, from 13.0% in 2007 to 24.7% in 2019]; P = .01 and 96% increase [13.0 percentage points, from 13.5% in 2007 to 26.5% in 2019]; P < .001), respectively; meanwhile, several specialties saw significant increases in female representation during this period (family medicine by 107.4%, P =.002; pediatrics by 83.1%, P =.006; OB/GYN by 53.2%, P =.045; orthopedic surgery by +4.1 percentage points, P =.04; general surgery by 226.9%, P =.005). In general, surgical specialties had lower leadership diversity than the average diversity of all residency programs, whereas primary care specialties had similar or increased diversity. Conclusions and Relevance: Study results suggest that some specialties have made significant contributions toward bridging diversity gaps whereas others continue to lag behind. Our recommendations to improve academic medical leadership diversity include programs and institutions (1) publishing efforts and outcomes of diversity representation, (2) incorporating a representative demographic for leadership selection committees, and (3) actively promoting the importance of diversity throughout the selection process.

Do Orthopaedic Virtual Clinic Visits Demonstrate Cost and Time Efficiencies Compared With In-person Visits?

BACKGROUND: There are numerous reasons for the increased use of telemedicine in orthopaedic surgery, one of which is the perception that virtual visits are more cost-effective than in-person visits. However, to our knowledge, no studies have compared the cost and time investment of virtual versus in-person visits using the time-driven activity-based costing (TDABC) method. Unlike methods that estimate cost based on charges for services rendered, TDABC provides a more precise measurement of costs, which is essential for assessing cost-effective innovations and moving to value-based healthcare. QUESTIONS/PURPOSES: (1) Are virtual visits less costly than analogous in-person visits, as measured by TDABC? (2) Does TDABC yield cost estimates that are lower or higher than the ratio of costs to charges (RCC), which is a simple, frequently used costing method? (3) Do the total time commitments of healthcare personnel, and that of the surgeon specifically, vary between the virtual and in-person settings? METHODS: Patients for this prospective, observational study were recruited from the practices of the highest-volume virtual-visit surgeons of three subspecialties (joints, hand, and sports) in a multihospital, tertiary-care academic institution in a metropolitan area in the Midwestern United States. Each surgeon had at least 10 years of clinical practice. Between June 2021 and September 2021, we analyzed both in-person and virtual return visits with patients who had an established relationship with the surgeon, because this represented the most frequent type of virtual visits and enabled a direct comparison between the two settings. New patients were not included in the study because of the limited availability of new-patient virtual visits; such patients often benefit from in-person physical examinations and on-site imaging. Additionally, patients seen for routine postoperative care were excluded because they were primarily seen in person by a physician assistant. Data were acquired during this period until 90 in-person and 90 virtual visits were collected according to selection criteria; no patients were lost to follow-up. Distinct process maps, which represent the steps involved in a clinic visit used to measure healthcare personnel time invested, were constructed for in-person and virtual clinic visits and used to compare total personnel and surgeon time spent. To calculate TDABC-derived costs, time allocated by personnel to complete each step was measured and used to calculate cost based on each personnel member's yearly salary. From the accounting department of our hospital, we acquired RCC cost data according to the level of service for a return visit. RESULTS: The total median cost, as measured by TDABC, was USD 127 (IQR USD 111 to 163) for an in-person visit and USD 140 (IQR USD 113 to 205) for a virtual visit (median difference USD 13; p = 0.16). RCC overestimated TDABC-calculated direct variable cost in five of six service levels (in-person levels 3, 4, and 5 and virtual levels 3 and 5) by a range of USD 25 to 88. Additionally, we found that virtual visits consumed 4 minutes less of total personnel time (in-person: 17 minutes [IQR 13.5 to 23.5 minutes], virtual: 13 minutes [IQR 11 to 19 minutes]; p < 0.001); however, this difference in personnel time did not equate to cost savings because surgeons spent 2 minutes longer on virtual visit activities than they did on in-person activities (in-person: 6 minutes [IQR 4.5 to 9.5 minutes], virtual: 8 minutes [IQR 5.5 to 13 minutes]; p = 0.003). CONCLUSION: Orthopaedic virtual visits did not deliver cost savings compared with in-person visits because surgeons spent more time on virtual visits and participated in virtual visits at the clinical site. Additionally, as anticipated, RCC overestimated costs as calculated by TDABC. These findings suggest that cost is not a primary advantage of transitioning to virtual visits, and that factors such as patient preference and satisfaction should be considered instead. LEVEL OF EVIDENCE: Level II, economic and decision analysis.

The Utility of Fluorescence Recovery after Photobleaching (FRAP) to Study the Plasma Membrane.

The plasma membrane of mammalian cells is involved in a wide variety of cellular processes, including, but not limited to, endocytosis and exocytosis, adhesion and migration, and signaling. The regulation of these processes requires the plasma membrane to be highly organized and dynamic. Much of the plasma membrane organization exists at temporal and spatial scales that cannot be directly observed with fluorescence microscopy. Therefore, approaches that report on the membrane's physical parameters must often be utilized to infer membrane organization. As discussed here, diffusion measurements are one such approach that has allowed researchers to understand the subresolution organization of the plasma membrane. Fluorescence recovery after photobleaching (or FRAP) is the most widely accessible method for measuring diffusion in a living cell and has proven to be a powerful tool in cell biology research. Here, we discuss the theoretical underpinnings that allow diffusion measurements to be used in elucidating the organization of the plasma membrane. We also discuss the basic FRAP methodology and the mathematical approaches for deriving quantitative measurements from FRAP recovery curves. FRAP is one of many methods used to measure diffusion in live cell membranes; thus, we compare FRAP with two other popular methods: fluorescence correlation microscopy and single-particle tracking. Lastly, we discuss various plasma membrane organization models developed and tested using diffusion measurements.

AOA Critical Issues: Gender Justice in Academic Medicine: What It Might Look Like in Orthopaedic Surgery.

ABSTRACT: As the number of women entering medicine has increased, so has the number of women entering orthopaedics; however, many orthopaedic programs struggle to create an equitable space for women, particularly in leadership. Struggles experienced by women include sexual harassment and gender bias, lack of visibility, lack of well-being, disproportionate family care responsibilities, and lack of flexibility in the criteria for promotions. Historically, sexual harassment and bias has been a problem faced by women physicians, and often the harassment continues even when the issue has been reported; many women find that reporting it results in negative consequences for their career and training. Additionally, throughout medical training, women are less exposed to orthopaedics and lack the mentorship that is given to their colleagues who are men. The late exposure and lack of support prevent women from entering and advancing in orthopaedic training. Typical surgery culture can also result in women orthopaedic surgeons avoiding help for mental wellness. Improving well-being culture requires systemic changes. Finally, women in academics perceive decreased equality in promotional considerations and face leadership that already lacks representation of women. This paper presents solutions to assist in developing equitable work environments for all academic clinicians.

Decision Aid on Orthopedic Virtual Care: Patient Preferences in Orthopedic Hand Clinic.

Introduction: The objectives of this study are to develop a decision aid for orthopedic patients to decide between virtual or in-person care and assess patient preferences for these modalities in hand clinic. Methods: An orthopedic virtual care decision aid was developed alongside orthopedic surgeons and a virtual care expert. Subject participation involved 5 steps: Orientation, Memory, and Concentration Test (OMCT), knowledge pretest, decision aid, postdecision aid questionnaire, and Decisional Conflict Scale (DCS) assessment. Patients presenting to hand clinic were initially provided the OMCT to assess decision-making capacity, with those failing excluded. Subjects were then administered a pretest to assess their understanding of virtual and in-person care. Subsequently, the validated decision aid was provided to patients, after which a postdecision aid questionnaire and DCS assessment were administered. Results: This study enrolled 124 patients. Pre- to postdecision aid knowledge test scores increased by 15.3% (p < 0.0001), and the average patient DCS score was 18.6. After reading the decision aid, 47.6% of patients believed that virtual and in-person care provided similar physician interaction, 46.0% felt little difference in effectiveness between the modalities, and 39.5% had no preference for either. Most patients understood their options (79.8%) and were ready to make a care modality decision (65.4%) following decision aid administration. Conclusion: Significant improvements in knowledge scores, strong DCS scores, and high levels of understanding and decision-making readiness support decision aid validity. Hand patients appear to have no consensus preferences for care modality, emphasizing the need for a decision aid to help determine individual care preferences.

AOA Critical Issues Symposium: Deficit Recovery for the Orthopaedic Service Line.

ABSTRACT: The COVID-19 pandemic and the mandated cessation of surgical procedures for a substantial portion of the 2020 year placed tremendous strain, both clinically and financially, on the health-care system in the United States. As a surgical specialty that accounts for nearly a quarter of all hospital net income, the revenue recovery of orthopaedic service lines (OSLs) is of particular importance to the financial recovery of their broader health-care institutions. In this American Orthopaedic Association (AOA) symposium report, the OSL leaders from 4 major academic medical institutions explain and reflect on their approaches to address their revenue deficits. Cost-reduction strategies, such as tightening budgets, adopting remote-work models, and limiting costs of human capital, were vital to stabilizing departmental finances at the onset of the pandemic, while strategies that focused on expanding surgical volume, such as those that improve efficiency in clinical and surgical settings, were important in growing revenue once elective procedures resumed. Institutional policy, payer administrative procedures, and the overall context of an ongoing public health crisis all placed limitations on recovery efforts, but engaging relevant stakeholders and working with available resources helped OSLs overcome these limitations. Due to clear strategic actions that were taken to address their deficits, each OSL represented in this AOA symposium saw substantial improvement in its year-end financial performance compared with its financial status at the end of the period of mandatory cessation of elective surgical cases.

What are the Minimum Clinically Important Difference Values for the PROMIS and QuickDASH After Carpal Tunnel Release? A Prospective Cohort Study.

BACKGROUND: To better define the clinical significance of patient-reported outcomes, the concept of a minimum clinically important difference (MCID) exists. The MCID is the minimum change that a patient will perceive as meaningful. Prior attempts to determine the MCID after carpal tunnel release are limited by methodologic concerns, including the lack of a true anchor-based MCID calculation. QUESTIONS/PURPOSES: To address previous methodologic concerns in existing studies, as well as establish a clinically useful value for clinicians, we asked: What are the MCID values for the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE), PROMIS Pain Interference (PI), and the QuickDASH after carpal tunnel release? METHODS: We conducted a prospective cohort study at an urban, Midwest, multihospital, academic health system. One hundred forty-seven adult patients undergoing unilateral carpal tunnel release between September 2020 and February 2022 were identified. PROMIS UE, PI, and QuickDASH scores were collected preoperatively and 3 months postoperatively. We also collected responses to an anchor-based question: "Since your treatment, how would you rate your overall function?" (much worse, worse, slightly worse, no change, slightly improved, improved, or much improved). Patients who did not respond to the 3-month postoperative surveys were excluded. A total of 122 patients were included in the final analysis (83% response proportion [122 of 147]). The mean age was 57 years (range 23 to 87 years), and 68% were women. The MCID was calculated using both anchor-based and distribution-based methods. Although anchor-based calculations are generally considered more clinically relevant because they consider patients' perceptions of improvement, an estimation of the minimum detectable change (which represents measurement error) relies on a distribution-based calculation. We determined a range of MCID values to propose a final MCID value for all three instruments. A negative MCID value for the PROMIS PI instrument represents a decrease in pain, whereas a positive value for the PROMIS UE instrument represents an improvement in function. A negative value for the QuickDASH instrument represents an increase in function. RESULTS: The final proposed MCID values were 6.2 (interquartile range [IQR] 5.4 to 9.0) for the PROMIS UE, -7.8 (IQR -6.1 to -8.5) for the PROMIS PI, and -18.2 (IQR -13.3 to -34.1) for the QuickDASH. CONCLUSION: We recommend that clinicians use the following values as the MCID after carpal tunnel release: 6 for the UE, -8 for the PI, and -18 for the QuickDASH. Surgeons may find these values useful when counseling patients postoperatively regarding improvement. Future studies could examine whether a single MCID (or small range) for PROMIS instruments is applicable to a variety of conditions and interventions. LEVEL OF EVIDENCE: Level II, therapeutic study.

H3K27me3 in Diffuse Midline Glioma and Epithelial Ovarian Cancer: Opposing Epigenetic Changes Leading to the Same Poor Outcomes.

Histone post-translational modifications modulate gene expression through epigenetic gene regulation. The core histone H3 family members, H3.1, H3.2, and H3.3, play a central role in epigenetics. H3 histones can acquire many post-translational modifications, including the trimethylation of H3K27 (H3K27me3), which represses transcription. Triple methylation of H3K27 is performed by the histone methyltransferase Enhancer of Zeste Homologue 2 (EZH2), a component of the Polycomb Repressive Complex 2. Both global increases and decreases in H3K27me3 have been implicated in a wide range of cancer types. Here, we explore how opposing changes in H3K27me3 contribute to cancer by highlighting its role in two vastly different cancer types; (1) a form of glioma known as diffuse midline glioma H3K27-altered and (2) epithelial ovarian cancer. These two cancers vary widely in the age of onset, sex, associated mutations, and cell and organ type. However, both diffuse midline glioma and ovarian cancer have dysregulation of H3K27 methylation, triggering changes to the cancer cell transcriptome. In diffuse midline glioma, the loss of H3K27 methylation is a primary driving factor in tumorigenesis that promotes glial cell stemness and silences tumor suppressor genes. Conversely, hypermethylation of H3K27 occurs in late-stage epithelial ovarian cancer, which promotes tumor vascularization and tumor cell migration. By using each cancer type as a case study, this review emphasizes the importance of H3K27me3 in cancer while demonstrating that the mechanisms of histone H3 modification and subsequent gene expression changes are not a one-size-fits-all across cancer types.

Development and validation of a military fear avoidance questionnaire.

Chronic pain due to musculoskeletal injury is one of the leading causes of disability and reduced combat readiness in the U.S. Army. Unidimensional pain management systems are not effective in addressing the complex phenomenon of pain-related disability. Growing evidence has supported use of the Fear Avoidance Model (FAM) as a suitable model to address pain-related disability and chronicity from a multidimensional pain neuroscience approach. While several fear avoidance measurement tools exist, one that addresses the complexity of the Army environment encouraged the authors to develop and test the reliability and validity of a military specific questionnaire. This study developed and validated an Army specific fear avoidance screening, the Return to Duty Readiness Questionnaire (RDRQ), which subsequently demonstrated good psychometric properties. Reliability coefficients demonstrate high internal consistency values both during pilot study (α = 0.96) and validation study (α = 0.94, ωt = 0.94). A Correlation Coefficient of 0.74 when compared with the Fear Avoidance Components Scale (FACS) suggests good concurrent validity. Future study should include replication in a new army population, investigation of responsiveness, test-retest reliability, structural validity and establishing severity scores with minimal clinically important differences to enhance utility.

Racial, Ethnic, and Gender Diversity in Academic Orthopaedic Surgery Leadership.

BACKGROUND: Multiple investigations in the past 50 years have documented a lack of racial/ethnic and gender diversity in the orthopaedic surgery workforce when compared with other specialties. Studies in other industries suggest that diversification of leadership can help diversify the underlying workforce. This study investigates changes in racial/ethnic and gender diversity of orthopaedic surgery leadership from 2007 to 2019 and compares leadership diversity to that of other surgical and nonsurgical specialties, specifically in terms of chairpersons and program directors. METHODS: Demographic data were collected from The Journal of the American Medical Association and the Association of American Medical Colleges. Aggregate data were utilized to determine the racial, ethnic, and gender composition of academic leadership for 8 surgical and nonsurgical specialties in 2007 and 2019. Comparative analysis was conducted to identify changes in diversity among chairpersons between the 2 years. Furthermore, current levels of diversity in orthopaedic leadership were compared with those of other specialties. RESULTS: A comparative analysis of diversity among program directors revealed that orthopaedic surgery had significantly lower minority representation (20.5%) when compared with the nonsurgical specialties (adjusted p < 0.01 for all) and, with the exception of neurological surgery, had the lowest proportion of female program directors overall, at 9.0% (adjusted p < 0.001 for all). From 2007 to 2019, orthopaedic surgery experienced no change in minority representation among chairpersons (adjusted p = 0.73) but a significant increase in female representation among chairpersons, from 0.0% (0 of 102) to 4.1% (5 of 122) (adjusted p = 0.04). Lastly, a significant decrease in minority and female representation was observed when comparing the diversity of 2019 orthopaedic faculty to orthopaedic leadership in 2019/2020 (p < 0.05 for all). CONCLUSIONS: Diversity in orthopaedic surgery leadership has improved on some key fronts, specifically in gender diversity among chairpersons. However, a significant decrease in minority and gender representation was observed between 2019 orthopaedic faculty and 2019/2020 orthopaedic leadership (p < 0.05), which was a trend shared by other specialties. These findings may suggest a more pervasive problem in diversity of medical leadership that is not only limited to orthopaedic surgery.

First Report of Didymella rhei causing leaf spot on rhubarb in New York.

First Report of Didymella rhei causing leaf spot on rhubarb in New York E. J. Indermaur1, C. T. C. Day1, and C. D. Smart1† 1School of Integrative Plant Science, Section of Plant Pathology and Plant-Microbe Biology, Cornell University, Geneva NY 14456 †Corresponding author: C. D. Smart; Email: cds14@cornell.edu Rhubarb (Rheum spp.) is a perennial grown across the northern United States for petiole production (Foust & Marshall 1991). In August 2021, leaf spots were observed on rhubarb growing in a two-acre field in Erie Co., NY (Fig. S1). Approximately 30% of the plants in the field had leaf spot with disease severity of 5%. Initial symptoms on leaves were light brown, circular lesions with red margins that later coalesced into irregular spots. Lesion centers were dry with concentric rings, often perforating as they enlarged. Lesions on petioles were light brown, fusiform, and sunken with red margins. To identify the causal agent(s), symptomatic leaves and petioles from 50 plants (cultivar unknown) were collected with a W-shape sampling scheme. Lesion margins were surface sterilized with 70% ethanol for 60 s, 10% bleach for 60 s, rinsed in sterile water, plated on acidified potato dextrose agar (PDA), and incubated for two to four days at 20˚C. Hyphal tips from colony edges were transferred to new PDA plates. After 20 days, colonies (n=53) were olivaceous buff to grey olivaceous, producing white to grey, sparse aerial mycelium. Brown to black pycnidia were produced within five days in concentric rings around plate centers. Pycnidia were globose to subglobose, with one to two non-papillate or slightly papillate ostioles, and with mean diameter 75.8 (30.8 to 113.5) µm (n=20). Conidia were hyaline, ellipsoid or allantoid, and aseptate with mean ± SD dimensions of 6.2 ± 0.4 (4.9 to 8.1) x 2.2 ± 0.4 (1.3 to 3.3) µm (n=30) (Fig. S2). Based on these morphological characteristics, the isolates were initially identified as Didymella rhei [Ellis & Everh] (Qian Chen & L. Cai) (Boerema 2004). To confirm the identity, mycelia were scraped from PDA plates and homogenized using a TissueLyser II (Qiagen Inc.). Genomic DNA was extracted with a DNeasy Plant Mini Kit following manufacturer's instructions (Qiagen Inc.). PCR assays with primers ITS 4 and ITS 5 and fRPB2-7cR and RPB2-5F2 (Liu et al. 1999; Sung et al. 2007) were used to amplify the internal transcribed spacer (ITS) and the rpb2 gene regions of one representative isolate (strain RHU21204). Products were sequenced using Sanger chemistry. The sequences were deposited in GenBank with accession numbers OM903952 (ITS) and OM925897 (rpb2). The ITS and rpb2 sequences exhibited 99% (492/494 bp) and 100% (846/846 bp) identity with D. rhei accessions KF531831.1 and KP330428.1, respectively. Based on morphological and molecular characteristics, the pathogen was identified as D. rhei. To fulfill Koch's postulates, healthy leaves and petioles of four rhubarb seedlings (cultivars unknown) were spray-inoculated with a conidial suspension (1 × 107 conidia/ml) containing 0.2% Tween-20 from strain RHU21204. A tween suspension with no conidia was used as a control. Each treatment had three replicates. After inoculation, plants were placed in a 19˚C growth chamber with a 12-h photoperiod and misted for 30 min twice daily to maintain humidity above 80%. Initial symptoms were observed five days post inoculation (dpi), while control plants were asymptomatic. The pathogen was isolated 21 dpi from inoculated leaves and petioles with symptoms as described above (Fig. S1) and identified morphologically and molecularly as D. rhei. A representative isolate was deposited in the Cornell Plant Pathology Herbarium as CUP-070923. To our knowledge, this is the first report of D. rhei causing rhubarb leaf spot in New York and reducing the health and marketability of its host. Funding Source This project was funded by the College of Agriculture and Life Sciences, Cornell University. Literature Cited Boerema, G. H. et al. 2004. CABI Publishing. 288. Foust, C. M. and Marshall, D. E. 1991. HortScience 26:1360. DOI: 10.21273/HORTSCI.26.11.1360 Liu, Y. J. et al. 1999. Mol. Biol. Evol. 16:1799. Sung, G. H. et al. 2007. Mol. Phylogenet. Evol. 44:1204. DOI: 10.1016/j.ympev.2007.03.011.

Workplace-related musculoskeletal injury trends in the United States from 1992 to 2018.

INTRODUCTION: The purpose of our study is to assess workplace-related musculoskeletal (wrMSK) injury trends by utilizing Bureau of Labor Statistics (BLS) data. We hypothesize that trunk injuries are the most commonly reported, injuries occur most frequently in the manufacturing sector, and that injury type occurrence differs according to body region affected. METHODS: This study assessed wrMSK injury data provided by the BLS from 1992 to 2018. The three main body regions analyzed were lower extremity (LE), upper extremity (UE), and trunk. Injury data was also assessed by industrial sector (Agriculture, Manufacturing, Healthcare, and Construction) and injury type (fractures, multiple injuries, sprains/strains/tears, tendonitis, cuts/lacerations, pain/soreness, and bruises). Negative binomial regression and pairwise comparisons with a Benjamini-Hochberg adjustment were utilized to compare calculated incidence rate ratios for wrMSK injuries. Exponentiated beta estimates were used to calculate the estimated annual percent changes of wrMSK injuries within each industrial sector. RESULTS: Occurrence of wrMSK injuries from 1992 to 2018 was significantly lower for LE when compared to both upper extremity and trunk (p < 0.001). Manufacturing is shown to be the industry with the most wrMSK injuries in each of UE, LE, and trunk. wrMSK injuries were shown to decrease in each industrial sector over the timespan assessed, with the greatest percent change occurring in the manufacturing sector. Lacerations and tendonitis were the most common diagnosis types in UE, while pain/soreness and strains/sprains/tears were most common in trunk and bruises were most common in LE. DISCUSSION: From 1992 to 2018, trunk injuries were the most frequently occurring wrMSK injury, but not to a significantly higher degree than upper extremity injuries. wrMSK injury types that may require orthopedic surgical care affect specific body regions to different degrees, with cuts/lacerations and tendonitis most commonly affecting the upper extremity. Thus, it appears that wrMSK injuries in the upper extremity are of particular importance from an orthopedic care perspective.