Trends in the Utilization of Computed Tomography in Operative Treatment of Distal Radius Fractures.

Purpose: To identify patient, surgeon, and injury characteristics associated with preoperative computed tomography (CT) scan utilization for operative distal radius fractures (DRF). In addition, we aimed to determine if preoperative CT was associated with treatment methods other than isolated volar-locked plating (VLP). Methods: We retrospectively reviewed all operatively treated adult DRFs within our health care system from 2016 to 2020. Baseline demographics, injury, treatment characteristics, and the fellowship training of the 44 included surgeons were recorded. We compared cases with and without a preoperative CT, and an adjusted logistic regression model was generated to determine the odds of having a preoperative CT. Results: A total of 1,204 operatively treated DRFs performed by 44 surgeons were included. CT utilization increased during the study period. Intra-articular fractures accounted for 76% of cases, and preoperative CT scans were ordered in 243 of 1240 cases (20%). Overall, isolated VLP was used in 83% of cases. Cases with a preoperative CT were more likely to be treated with an alternative method of fixation (such as dorsal plating). The adjusted logistic regression model demonstrated that male sex (OR 1.62; 95% CI: 1.16, 2.26), intra-articular fractures (OR 3.11; 95% CI: 1.87, 5.81), and associated fractures (OR 2.69; 95% CI: 1.82, 3.98) had a significantly increased odds of having a preoperative CT. Fellowship training was not associated with increased CT utilization overall, but hand surgeons were more likely to use a CT in Orthopaedic Trauma Association-C3 fractures. Conclusions: Patient and injury characteristics are associated with CT utilization in operative DRFs. Preoperative CTs are associated with alternative fixation approaches, as cases with a CT were more likely to use fixation methods other than isolated VLP. The costs and benefits of CT scans must be carefully weighed against whether this modality adds value or improves outcomes in treating DRFs. Level of evidence: Prognostic II.

Publicly Disclosed Pricing for Common Upper-Extremity Procedures: An Analysis of Hospital Chargemasters.

BACKGROUND: American hospitals are required to provide price transparency data (known as a chargemaster) for medical services, which is intended to allow consumers to accurately estimate the cost of medical services. Our purpose was to identify hospital compliance in publishing chargemaster documents and to assess the price information published for common upper-extremity services and procedures. METHODS: We performed a cross-sectional analysis of publicly available chargemaster data from 122 hospitals, which included the top-20-ranked Honor Roll hospitals from US News and World Report and 2 top-ranked hospitals from each state. Chargemaster files were accessed for each hospital, and price information was recorded for 10 common upper-extremity procedures including radiographs, injections, and surgeries. Mean procedural prices were compared between academic and nonacademic hospitals. RESULTS: Chargemaster files were able to be accessed for 107 (88%) of 122 institutions. Price estimates for imaging studies were more frequently reported (73%) than those of procedures (23%-41%). With 50 hospitals reporting a price estimate, carpal tunnel injection was the most frequently reported procedure, whereas trigger finger release was the least frequently reported (41% and 23%, respectively). Wide price ranges were noted, with mean charges for a total shoulder arthroplasty listed as US $51 723 (range, US $247-US $364 024). Mean prices between academic and nonacademic hospital systems were similar. CONCLUSIONS: While most (88%) of the included hospitals have been compliant with publishing their price transparency files, price estimates for common upper-extremity procedures and imaging studies are inconsistently reported and, when present, demonstrate high levels of price variability between and within hospital systems.

The Reliability of the CTS-6 for Examiners With Varying Levels of Clinical Experience.

PURPOSE: To assess the interrater reliability of the CTS-6 for examiners with varying levels of clinical expertise. We also aimed to analyze this instrument's sensitivity (Sn) and specificity (Sp), using the CTS-6 score obtained by a hand surgeon as a reference standard. METHODS: Three examining groups consisting of medical students, occupational hand therapists, and hand surgeons examined a consecutive series of patients in an academic upper-extremity clinic. A total of 3 examiners (1 from each group) recorded a CTS-6 score for each patient. The examiners were blinded to the scores from the other groups. The interrater reliability was determined between the groups with respect to the diagnosis of CTS and the individual CTS-6 components. Sn and Sp were calculated for each of the groups using the CTS-6 obtained by the hand surgeons as the reference standard. RESULTS: Two hundred seven patients were included. For the diagnosis of CTS (CTS-6 score of 12 or greater as determined by a hand surgeon), there was substantial agreement between the 3 groups (Fleiss kappa 0.73; 95% CI [0.65 -0.82]; P < .05). For individual CTS-6 components, the agreement between the groups was highest for assessing subjective numbness and lowest for assessing a Tinel sign (Fleiss kappa of 0.77 and 0.49, respectively). The Sn/Sp for diagnosing CTS was 87%/91% for the medical student group and 81%/95% for the occupational hand therapist group. CONCLUSIONS: The CTS-6 can be reliably used as a screening and diagnostic tool for CTS by clinicians with a variety of experience levels and without specific fellowship training in upper-extremity surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic I.

Ground Same Intratransport Efficacy as Air for Acute Aortic Diseases.

INTRODUCTION: Patients with acute aortic diseases (AAoD) usually require transfer to tertiary centers for possible surgical care, for which intratransport management represents important continuing spectrum of care. There is little information comparing intratransport efficacy of air (ART) vs ground transport (GRT), nor how effectively they manage these patients' pain. Our study aims to compare how effective ART and GRT manage patients' intratransport HR, pressure. METHODS: Charts were reviewed of adult patients interhospital transferred to a quaternary academic center (UMMC) between 01/01/2011 and 09/30/2015. Outcomes were percentages of patients achieving target hemodynamic parameters, mortality. RESULTS: We analyzed 226 patients, 58 (26%) transported by Air and 102 (45%) type A dissection. Ground transport was associated with higher percentage of patients with target HR 60-80 bpm comparing to ART (58% vs 43%, 95% CI 0.3-0.99). Both ART and GRT were associated with similar frequencies of patients achieving target SBP and adequate pain control. Time intervals from transfer request to surgery, and mortality were similar for both types of transport. CONCLUSION: Ground transport teams were more successful at achieving predefined target heart rate than Air transport. Intra-transport management of other vital signs and pain were equally effectively between both Air and Ground transport.

Assessing adequacy of emergency provider documentation among interhospital transferred patients with acute aortic dissection.

BACKGROUND: Acute aortic dissection (AoD) is a hypertensive emergency often requiring the transfer of patients to higher care hospitals; thus, clinical care documentation and compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA) is crucial. The study assessed emergency providers (EP) documentation of clinical care and EMTALA compliance among interhospital transferred AoD patients. METHODS: This retrospective study examined adult patients transferred directly from a referring emergency department (ED) to a quaternary academic center between January 1, 2011 and September 30, 2015. The primary outcome was the percentage of records with adequate documentation of clinical care (ADoCC). The secondary outcome was the percentage of records with adequate documentation of EMTALA compliance (ADoEMTALA). RESULTS: There were 563 electronically identified patients with 287 included in the final analysis. One hundred and five (36.6%) patients had ADoCC while 166 (57.8%) patients had ADoEMTALA. Patients with inadequate documentation of EMTALA (IDoEMTALA) were associated with a higher likelihood of not meeting the American Heart Association (AHA) ED Departure SBP guideline (OR 1.8, 95% CI 1.03-3.2, P=0.04). Male gender, handwritten type of documentation, and transport by air were associated with an increased risk of inadequate documentation of clinical care (IDoCC), while receiving continuous infusion was associated with higher risk of IDoEMTALA. CONCLUSION: Documentation of clinical care and EMTALA compliance by Emergency Providers is poor. Inadequate EMTALA documentation was associated with a higher likelihood of patients not meeting the AHA ED Departure SBP guideline. Therefore, Emergency Providers should thoroughly document clinical care and EMTALA compliance among this critically ill group before transfer.

Assessing adequacy of emergency provider documentation among interhospital transferred patients with acute aortic dissection / 世界急诊医学杂志（英文）

BACKGROUND@# Acute aortic dissection (AoD) is a hypertensive emergency often requiring the transfer of patients to higher care hospitals; thus, clinical care documentation and compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA) is crucial. The study assessed emergency providers (EP) documentation of clinical care and EMTALA compliance among interhospital transferred AoD patients.@*METHODS@# This retrospective study examined adult patients transferred directly from a referring emergency department (ED) to a quaternary academic center between January 1, 2011 and September 30, 2015. The primary outcome was the percentage of records with adequate documentation of clinical care (ADoCC). The secondary outcome was the percentage of records with adequate documentation of EMTALA compliance (ADoEMTALA).@*RESULTS@# There were 563 electronically identified patients with 287 included in the final analysis. One hundred and five (36.6%) patients had ADoCC while 166 (57.8%) patients had ADoEMTALA. Patients with inadequate documentation of EMTALA (IDoEMTALA) were associated with a higher likelihood of not meeting the American Heart Association (AHA) ED Departure SBP guideline (OR 1.8, 95% CI 1.03–3.2, P=0.04). Male gender, handwritten type of documentation, and transport by air were associated with an increased risk of inadequate documentation of clinical care (IDoCC), while receiving continuous infusion was associated with higher risk of IDoEMTALA.@*CONCLUSION@# Documentation of clinical care and EMTALA compliance by Emergency Providers is poor. Inadequate EMTALA documentation was associated with a higher likelihood of patients not meeting the AHA ED Departure SBP guideline. Therefore, Emergency Providers should thoroughly document clinical care and EMTALA compliance among this critically ill group before transfer.

3D bioprinting mesenchymal stem cell-laden construct with core-shell nanospheres for cartilage tissue engineering.

Cartilage tissue is prone to degradation and has little capacity for self-healing due to its avascularity. Tissue engineering, which provides artificial scaffolds to repair injured tissues, is a novel and promising strategy for cartilage repair. 3D bioprinting offers even greater potential for repairing degenerative tissue by simultaneously integrating living cells, biomaterials, and biological cues to provide a customized scaffold. With regard to cell selection, mesenchymal stem cells (MSCs) hold great capacity for differentiating into a variety of cell types, including chondrocytes, and could therefore be utilized as a cartilage cell source in 3D bioprinting. In the present study, we utilize a tabletop stereolithography-based 3D bioprinter for a novel cell-laden cartilage tissue construct fabrication. Printable resin is composed of 10% gelatin methacrylate (GelMA) base, various concentrations of polyethylene glycol diacrylate (PEGDA), biocompatible photoinitiator, and transforming growth factor beta 1 (TGF-ß1) embedded nanospheres fabricated via a core-shell electrospraying technique. We find that the addition of PEGDA into GelMA hydrogel greatly improves the printing resolution. Compressive testing shows that modulus of the bioprinted scaffolds proportionally increases with the concentrations of PEGDA, while swelling ratio decreases with the increase of PEGDA concentration. Confocal microscopy images illustrate that the cells and nanospheres are evenly distributed throughout the entire bioprinted construct. Cells grown on 5%/10% (PEGDA/GelMA) hydrogel present the highest cell viability and proliferation rate. The TGF-ß1 embedded in nanospheres can keep a sustained release up to 21 d and improve chondrogenic differentiation of encapsulated MSCs. The cell-laden bioprinted cartilage constructs with TGF-ß1-containing nanospheres is a promising strategy for cartilage regeneration.

A 3D printed nano bone matrix for characterization of breast cancer cell and osteoblast interactions.

Bone metastasis is one of the most prevalent complications of late-stage breast cancer, in which the native bone matrix components, including osteoblasts, are intimately involved in tumor progression. The development of a successful in vitro model would greatly facilitate understanding the underlying mechanism of breast cancer bone invasion as well as provide a tool for effective discovery of novel therapeutic strategies. In the current study, we fabricated a series of in vitro bone matrices composed of a polyethylene glycol hydrogel and nanocrystalline hydroxyapatite of varying concentrations to mimic the native bone microenvironment for the investigation of breast cancer bone metastasis. A stereolithography-based three-dimensional (3D) printer was used to fabricate the bone matrices with precisely controlled architecture. The interaction between breast cancer cells and osteoblasts was investigated in the optimized bone matrix. Using a Transwell® system to separate the two cell lines, breast cancer cells inhibited osteoblast proliferation, while osteoblasts stimulated breast cancer cell growth, whereas, both cell lines increased IL-8 secretion. Breast cancer cells co-cultured with osteoblasts within the 3D bone matrix formed multi-cellular spheroids in comparison to two-dimensional monolayers. These findings validate the use of our 3D printed bone matrices as an in vitro metastasis model, and highlights their potential for investigating breast cancer bone metastasis.