Utilizing Lean Leadership Principles to Build an Academic Primary Care Practice of the Future.

This Perspective presents a case study of multidimensional clinical transformation in an academic general internal medicine practice. In the face of increasing internal and external pressures, health systems and individual medical practices have pursued multiple strategies to improve quality, patient experience, and efficiency, while reducing staff and provider stress and burnout. We describe a Lean-informed approach that emphasizes the importance of organizational alignment in goals, evidence-based problem solving, and leadership behaviors to support a culture of continuous improvement. Our aim in this Perspective is to provide a real-world example of a feasible process for the planning, preparation, and execution of effective transformation, and to present lessons that may be useful to other academic health center practices seeking to develop innovative models to achieve the quadruple aim.

Inhibition of ovarian development and instances of sex reversal in genotypic female sablefish (Anoplopoma fimbria) exposed to elevated water temperature.

This study determined high temperature effects on ovarian development in a marine groundfish species, sablefish (Anoplopoma fimbria), with potential application in sex reversal or sterilization for aquaculture. Monosex female (XX-genotype) sablefish larvae (∼30 mm) were randomly divided into three groups and exposed to control (15.6 °C ±â€¯0.8 °C), moderate (20.4 °C ±â€¯0.5 °C), or high (21.7 °C ±â€¯0.5 °C) temperatures for 19 weeks. Treated fish were then tagged and transferred to ambient seawater (11.2 °C ±â€¯2.3 °C) for one year to determine whether temperature effects on reproductive development were maintained post-treatment. Fish were periodically sampled for gonadal histology, gene expression and plasma 17ß-estradiol (E2) analyses to assess gonadal development. Short-term (4-week) exposure to elevated temperatures had only minor effects, whereas longer exposure (12-19 weeks) markedly inhibited ovarian development. Fish from the moderate and high treatment groups had significantly less developed ovaries relative to controls, and mRNA levels for germ cell (vasa, zpc) and apoptosis-associated genes (p53, casp8) generally indicated gonadal degeneration. The high treatment group also had significantly reduced plasma E2 levels and elevated gonadal amh gene expression. After one year at ambient temperatures, however, ovaries of moderate and high treatment fish exhibited compensatory recovery and were indistinguishable from controls. Two genotypic females possessing immature testes (neomales) were observed in the high treatment group, indicating sex reversal had occurred (6% rate). These results demonstrate that extreme elevated temperatures may inhibit ovarian development or trigger sex reversal. High temperature treatment is likely not an effective sterilization method but may be preferable for sablefish neomale broodstock production.

Activated ERK1/2 increases CD44 in glomerular parietal epithelial cells leading to matrix expansion.

The glycoprotein CD44 is barely detected in normal mouse and human glomeruli, but is increased in glomerular parietal epithelial cells following podocyte injury in focal segmental glomerulosclerosis (FSGS). To determine the biological role and regulation of CD44 in these cells, we employed an in vivo and in vitro approach. Experimental FSGS was induced in CD44 knockout and wild-type mice with a cytotoxic podocyte antibody. Albuminuria, focal and global glomerulosclerosis (periodic acid-Schiff stain), and collagen IV staining were lower in CD44 knockout compared with wild-type mice with FSGS. Parietal epithelial cells had lower migration from Bowman's capsule to the glomerular tuft in CD44 knockout mice with disease compared with wild type mice. In cultured murine parietal epithelial cells, overexpressing CD44 with a retroviral vector encoding CD44 was accompanied by significantly increased collagen IV expression and parietal epithelial cell migration. Because our results showed de novo co-staining for activated ERK1/2 (pERK) in parietal epithelial cells in experimental FSGS, and also in biopsies from patients with FSGS, two in vitro strategies were employed to prove that pERK regulated CD44 levels. First, mouse parietal epithelial cells were infected with a retroviral vector for the upstream kinase MEK-DD to increase pERK, which was accompanied by increased CD44 levels. Second, in CD44-overexpressing parietal epithelial cells, decreasing pERK with U0126 was accompanied by reduced CD44. Finally, parietal epithelial cell migration was higher in cells with increased and reduced in cells with decreased pERK. Thus, pERK is a regulator of CD44 expression, and increased CD44 expression leads to a pro-sclerotic and migratory parietal epithelial cell phenotype.

Quality and equity of care in U.S. hospitals.

BACKGROUND: Nearly every U.S. hospital publicly reports its performance on quality measures for patients who are hospitalized for acute myocardial infarction, heart failure, or pneumonia. Because performance rates are not reported according to race or ethnic group, it is unclear whether improvements in equity of care have accompanied aggregate improvements in health care quality over time. METHODS: We assessed performance rates for quality measures covering three conditions (six measures for acute myocardial infarction, four for heart failure, and seven for pneumonia). These rates, adjusted for patient- and hospital-level covariates, were compared among non-Hispanic white, non-Hispanic black, and Hispanic patients who received care between 2005 and 2010 in acute care hospitals throughout the United States. RESULTS: Adjusted performance rates for the 17 quality measures improved by 3.4 to 57.6 percentage points between 2005 and 2010 for white, black, and Hispanic adults (P<0.001 for all comparisons). In 2005, as compared with adjusted performance rates for white patients, adjusted performance rates were more than 5 percentage points lower for black patients on 3 measures (range of differences, 12.3 to 14.2) and for Hispanic patients on 6 measures (5.6 to 14.5). Gaps decreased significantly on all 9 of these measures between 2005 and 2010, with adjusted changes for differences between white patients and black patients ranging from -8.5 to -11.8 percentage points and from -6.2 to -15.1 percentage points for differences between white patients and Hispanic patients. Decreasing differences according to race or ethnic group were attributable to more equitable care for white patients and minority patients treated in the same hospital, as well as to greater performance improvements among hospitals that disproportionately serve minority patients. CONCLUSIONS: Improved performance on quality measures for white, black, and Hispanic adults hospitalized for acute myocardial infarction, heart failure, or pneumonia was accompanied by increased racial and ethnic equity in performance rates both within and among U.S. hospitals. (Funded by the Centers for Medicare and Medicaid Services and the Veterans Affairs Health Services Research and Development Career Development Program.).

Increased Access to Professional Interpreters in the Hospital Improves Informed Consent for Patients with Limited English Proficiency.

BACKGROUND: Language barriers disrupt communication and impede informed consent for patients with limited English proficiency (LEP) undergoing healthcare procedures. Effective interventions for this disparity remain unclear. OBJECTIVE: Assess the impact of a bedside interpreter phone system intervention on informed consent for patients with LEP and compare outcomes to those of English speakers. DESIGN: Prospective, pre-post intervention implementation study using propensity analysis. SUBJECTS: Hospitalized patients undergoing invasive procedures on the cardiovascular, general surgery or orthopedic surgery floors. INTERVENTION: Installation of dual-handset interpreter phones at every bedside enabling 24-h immediate access to professional interpreters. MAIN MEASURES: Primary predictor: pre- vs. post-implementation group; secondary predictor: post-implementation patients with LEP vs. English speakers. Primary outcomes: three central informed consent elements, patient-reported understanding of the (1) reasons for and (2) risks of the procedure and (3) having had all questions answered. We considered consent adequately informed when all three elements were met. KEY RESULTS: We enrolled 152 Chinese- and Spanish-speaking patients with LEP (84 pre- and 68 post-implementation) and 86 English speakers. Post-implementation (vs. pre-implementation) patients with LEP were more likely to meet criteria for adequately informed consent (54% vs. 29%, p = 0.001) and, after propensity score adjustment, had significantly higher odds of adequately informed consent (AOR 2.56; 95% CI, 1.15-5.72) as well as of each consent element individually. However, compared to post-implementation English speakers, post-implementation patients with LEP had significantly lower adjusted odds of adequately informed consent (AOR, 0.38; 95% CI, 0.16-0.91). CONCLUSIONS: A bedside interpreter phone system intervention to increase rapid access to professional interpreters was associated with improvements in patient-reported informed consent and should be considered by hospitals seeking to improve care for patients with LEP; however, these improvements did not eliminate the language-based disparity. Additional clinician educational interventions and more language-concordant care may be necessary for informed consent to equal that for English speakers.

Dimethylsulfoniopropionate (DMSP) Increases Survival of Larval Sablefish, Anoplopoma fimbria.

High concentrations of dimethylsulfoniopropionate (DMSP), a chemical compound released by lysed phytoplankton, may indicate high rates of grazing by zooplankton and may thus be a foraging cue for planktivorous fishes. Previous studies have shown that some planktivorous fishes and birds aggregate or alter locomotory behavior in response to this chemical cue, which is likely adaptive because it helps them locate prey. These behavioral responses have been demonstrated in juveniles and adults, but no studies have tested for effects on larval fish. Larvae suffer from high mortality rates and are vulnerable to starvation. While larvae are generally thought to be visual predators, they actually have poor vision and cryptic prey. Thus, larval fish should benefit from a chemical cue that provides information on prey abundance. We reared larval sablefish, Anoplopoma fimbria, for one week and supplemented feedings with varying concentrations of DMSP to test the hypothesis that DMSP affects larval survival. Ecologically relevant DMSP concentrations increased larval survival by up to 70 %, which has implications for production in aquaculture and recruitment in nature. These results provide a new tool for increasing larval production in aquaculture and also suggest that larvae may use DMSP as an olfactory cue. The release of DMSP may be a previously unappreciated mechanism through which phytoplankton affect larval survival and recruitment.

Small-area spatio-temporal analyses of bladder and kidney cancer risk in Nova Scotia, Canada.

BACKGROUND: Bladder and kidney cancers are the ninth and twelfth most common type of cancer worldwide, respectively. Internationally, rates vary ten-fold, with several countries showing rising incidence. This study describes the spatial and spatio-temporal variations in the incidence risk of these diseases for Nova Scotia, a province located in Atlantic Canada, where rates for bladder and kidney cancer exceed those of the national average by about 25% and 35%, respectively. METHODS: Cancer incidence in the 311 Communities of Nova-Scotia was analyzed with a spatial autoregressive model for the case counts of bladder and kidney cancers (3,232 and 2,143 total cases, respectively), accounting for each Community's population and including variables known to influence risk. A spatially-continuous analysis, using a geostatistical Local Expectation-Maximization smoothing algorithm, modeled finer-scale spatial variation in risk for south-western Nova Scotia (1,810 bladder and 957 kidney cases) and Cape Breton (1,101 bladder, 703 kidney). RESULTS: Evidence of spatial variations in the risk of bladder and kidney cancer was demonstrated using both aggregated Community-level mapping and continuous-grid based localized mapping; and these were generally stable over time. The Community-level analysis suggested that much of this heterogeneity was not accounted for by known explanatory variables. There appears to be a north-east to south-west increasing gradient with a number of south-western Communities have risk of bladder or kidney cancer more than 10% above the provincial average. Kidney cancer risk was also elevated in various northeastern communities. Over a 12 year period this exceedance translated in an excess of 200 cases. Patterns of variations in risk obtained from the spatially continuous smoothing analysis generally mirrored those from the Community-level autoregressive model, although these more localized risk estimates resulted in a larger spatial extent for which risk is likely to be elevated. CONCLUSIONS: Modelling the spatio-temporal distribution of disease risk enabled the quantification of risk relative to expected background levels and the identification of high risk areas. It also permitted the determination of the relative stability of the observed patterns over time and in this study, pointed to excess risk potentially driven by exposure to risk factors that act in a sustained manner over time.

Antibiotic Therapy for Adults Hospitalized With Community-Acquired Pneumonia: A Systematic Review.

IMPORTANCE: Antibiotic therapy is the cornerstone of medical management for community-acquired pneumonia. OBJECTIVE: To assess the associations between 3 key aspects of antibiotic therapy (optimal time to antibiotic initiation, initial antibiotic selection, and criteria for the transition from intravenous to oral therapy) and short-term mortality in adults hospitalized with community-acquired pneumonia. EVIDENCE REVIEW: Bibliographic databases of MEDLINE, EMBASE, and the Cochrane Collaboration were searched for studies of adults hospitalized with radiographically confirmed community-acquired pneumonia published from January 1, 1995, until November 5, 2015. FINDINGS: Twenty studies (17 observational and 3 randomized trials) met eligibility criteria. Among 8 observational studies identified, the 4 largest (study populations of 2878 to 1,170,022) found that antibiotic initiation within 4 to 8 hours of hospital arrival was associated with relative reductions of 5% to 43% in mortality; the 4 smallest studies (study populations of 451 to 2076) found no associations between the timing of antibiotic initiation and mortality. One cluster randomized trial (n = 1737) demonstrated noninferiority of ß-lactam monotherapy (n = 506) vs ß-lactam plus macrolide combination therapy (n = 566), with an absolute adjusted difference of 2.5% (90% CI, -0.6% to 5.2%) in 90-day mortality favoring ß-lactam monotherapy. A second randomized trial (n = 580) failed to demonstrate noninferiority of ß-lactam monotherapy vs ß-lactam plus macrolide combination therapy, with an absolute difference of 7.6% (1-sided 90% CI upper limit, 13.0%) in attainment of clinical stability on hospital day 7 favoring ß-lactam plus macrolide combination therapy. Six of 8 observational studies (study populations of 1188 to 24,780) found that ß-lactam plus macrolide combination therapy was associated with relative reductions of 26% to 68% in short-term mortality and all 3 observational studies (study populations of 2068 to 24,780) reported that fluoroquinolone monotherapy was associated with relative reductions of 30% to 43% in mortality compared with ß-lactam monotherapy. One randomized trial (n = 302) reported significantly reduced hospital length of stay (absolute difference, 1.9 days; 95% CI, 0.6 to 3.2 days), but no differences in treatment failure when objective clinical criteria were used to decide when to transition patients from intravenous to oral therapy. CONCLUSIONS AND RELEVANCE: In adults hospitalized with community-acquired pneumonia, antibiotic therapy consisting of ß-lactam plus macrolide combination therapy or fluoroquinolone monotherapy initiated within 4 to 8 hours of hospital arrival was associated with lower adjusted short-term mortality, supported predominantly by low-quality observational studies. One randomized trial supports the use of objective clinical criteria to guide the transition from intravenous to oral antibiotic therapy.

Biceps tenotomy vs. tenodesis: an ACS-NSQIP analysis of postoperative outcomes and utilization trends.

Background: While studies have assessed comparative rates of restoration of shoulder function and alleviation of symptoms, comparative systemic postoperative complication rates between biceps tenotomy and tenodesis have yet to be assessed. The purpose of the present study was to use a national administrative database to perform a comprehensive investigation into 30-day complication rates after biceps tenotomy versus tenodesis, thus providing valuable insights for informed decision-making by clinicians and patients regarding the optimal surgical approach for pathologies of the long head of the biceps tendon. Methods: The National Surgical Quality Improvement Program database was queried to analyze postoperative complication rates and metrics associated with biceps tenotomy and tenodesis. Patient data spanning from 2012 to 2021 was extracted, with relevant variables assessed to identify and compare these two surgical approaches. Adjusted and unadjusted analyses were utilized to analyze patient demographics, comorbidities, operative times, lengths of stay, readmissions, adverse events, and yearly surgical volume, along with trends in usage, across cohorts. Results: Of 11,527 total patients, 264 (2.29%), 6826 (59.22%), and 4437 (38.49%) underwent tenotomy, tenodesis with open repair, and tenodesis with arthroscopic repair, respectively. Tenotomy operative times ([mean ± SD]: 66.25 ± 44.76 minutes) were shorter than those for open tenodesis (78.83 ± 41.82) and arthroscopic tenodesis (75.98 ± 40.16). Conversely, tenotomy patients had longer hospital days (0.88 ± 4.86 days) relative to open tenodesis (.08 ± 1.55) and arthroscopic tenodesis (.12 ± 2.70). Multivariable logistic regression controlling for demographics and comorbidities demonstrated that patients undergoing tenodesis were less likely to be readmitted (adjusted odds ratio [AOR]: 0.42, 95% confidence interval [CI]: 0.17-0.98, P = .050) or sustain serious adverse events (AOR: 0.27, 95% CI: 0.13-0.57, P < .001), but equally likely to sustain minor adverse events (AOR: 0.87, CI: 0.21-3.68, P = .850), compared with patients undergoing tenotomy. Lastly, comparing utilization rates from 2012 to 2021 revealed a significant decrease in the proportion of tenotomy (from 6.2% to 1.0%) compared to open tenodesis (from 41.0% to 57.3%) and arthroscopic tenodesis (52.8% to 41.64%; P trend = .001). Conclusion: To our knowledge, this is the first large national database study investigating postoperative complication rates between the various surgical treatments for pathologies of the long head of the biceps tendon. Our results suggest that tenodesis yields fewer serious adverse events and lower readmission rates than tenotomy. We also found a shorter operative time for tenotomy. These findings support the increased utilization of tenodesis relative to tenotomy in recent years.

AM-PAC Mobility Score <13 Predicts Development of Ileus Following Adult Spinal Deformity Surgery.

STUDY DESIGN: Retrospective review. OBJECTIVE: To determine whether the Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" score is associated with the development of postoperative ileus. SUMMARY OF BACKGROUND DATA: Adult spinal deformity (ASD) surgery has a high complication rate. One common complication is postoperative ileus, and poor postoperative mobility has been implicated as a modifiable risk factor for this condition. METHODS: Eighty-five ASD surgeries in which ≥5 levels were fused were identified in a single institution database. A physical therapist/physiatrist collected patients' daily postoperative AM-PAC scores, for which we assessed first, last, and daily changes. We used multivariable linear regression to determine the marginal effect of ileus on continuous AM-PAC scores; threshold linear regression with Bayesian information criterion to identify a threshold AM-PAC score associated with ileus; and multivariable logistic regression to determine the utility of the score thresholds when controlling for confounding variables. RESULTS: Ten of 85 patients (12%) developed ileus. The mean day of developing ileus was postoperative day 3.3±2.35. The mean first and last AM-PAC scores were 16 and 18, respectively. On bivariate analysis, the mean first AM-PAC score was lower in patients with ileus than in those without (13 vs. 16; P<0.01). Ileus was associated with a first AM-PAC score of 3 points lower (Coef. -2.96; P<0.01) than that of patients without ileus. Patients with an AM-PAC score<13 had 8 times greater odds of developing ileus (P=0.023). Neither the last AM-PAC score nor the daily change in AM-PAC score was associated with ileus. CONCLUSIONS: In our institutional cohort, a first AM-PAC score of <13, corresponding to an inability to walk or stand for more than 1 minute, was associated with the development of ileus. Early identification of patients who cannot walk or stand after surgery can help determine which patients would benefit from prophylactic management. LEVEL OF EVIDENCE: Level-III.

Association Between Severity of Chondrolabral Junction Breakdown and Functional Outcomes After Hip Arthroscopy for Acetabular Labral Tears.

BACKGROUND: Despite focus on surgical preservation of the chondrolabral junction (CLJ), the transition zone between the acetabular cartilage and labrum, the association between severity of CLJ breakdown and functional outcomes after hip arthroscopy remains unexplored. PURPOSE: To assess the influence of CLJ breakdown on patient-reported outcome measures (PROMs) at a 24-month follow-up after hip arthroscopy for symptomatic labral tears. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective review of prospectively collected data was conducted to identify patients ≥18 years of age with a minimum 24-month follow-up who underwent hip arthroscopy by a single surgeon for the treatment of symptomatic labral tears secondary to femoroacetabular impingement. The Beck classification of transition zone cartilage was used to grade CLJ damage; patients with grades 0 to 2 were stratified into the mild CLJ damage cohort, and those with grades 3 and 4 were stratified into the severe CLJ damage cohort. PROMs were collected at baseline and at 3, 6, 12 months, and annually thereafter postoperatively. Linear mixed-effects models were used to compare PROMs. Rates of achieving clinically meaningful thresholds and subsequent surgery rates were also compared. RESULTS: In total, 198 patients met the inclusion criteria, with a mean follow-up of 3.54 ± 1.26 years. A total of 95 patients with severe CLJ damage (mean age, 34.9 ± 10.5 years) were compared with 103 patients with mild CLJ damage (mean age, 38.2 ± 11.9 years). Hip Outcome Score-Activities of Daily Living (HOS-ADL), Non-Arthritic Hip Score (NAHS), and visual analog score for pain were inferior in the severe CLJ group at enrollment and all follow-up time points (P≤ .05). However, patients with severe CLJ breakdown exhibited greater improvements in HOS-ADL and NAHS at the 24-month follow-up and achieved clinically meaningful thresholds at equivalent rates to patients with mild CLJ breakdown. Subsequent surgery rates were 6.8% and 12.6% in patients with mild versus severe CLJ damage, respectively (P = .250). CONCLUSION: Severe CLJ breakdown is associated with increased pain and decreased functional level preoperatively and up to 24 months after hip arthroscopy. Despite this, patients with severe CLJ breakdown experienced greater improvements in functional outcomes at a 24-month follow-up and achieved clinical thresholds at similar rates to patients with mild CLJ damage. Thus, while worse baseline pain and functional levels may indicate severe CLJ breakdown, these patients still benefit substantially from hip arthroscopy.

Apophyseal ilium avulsion fractures in young athletes: a systematic review and return to sport analysis.

The purpose of the current investigation was to synthesize the epidemiology, cause, management, and return to sport (RTS) outcomes of ilium avulsion fractures sustained during sporting activities in young athletes. Studies reporting on athletes <18 years old sustaining an avulsion fracture along the ilium [injury to the anterior superior or inferior iliac spine (ASIS or AIIS), or the iliac crest (IC)], and the athlete's RTS status were included. RTS was analyzed by injury acuity, location, mechanism of injury, and management, whereas complications were recorded. Seventy studies comprising 286 avulsions (169 ASIS, 87 AIIS, and 30 IC) were included. The mean age of athletes was 14.5 + 1.3 years (range, 8-18 years). Sprinting (n = 103/286; 36.0%) and soccer (n = 97/286; 33.9%) were the most common sports during which injuries occurred. A total of 96.5% (n = 276/286) of athletes reported successful RTS at an average of 16.2 + 19.3 weeks. The RTS rate for patients sustaining ASIS, AIIS, and IC avulsions was 95.3, 97.7, and 100%, respectively. Acute trauma was responsible for 89.8% (n = 158/176) of injuries, which demonstrated a significantly faster (13.3 + 9.3 weeks) and higher RTS rate (99.4%) compared with those with chronic avulsions (74.4 + 40.9 weeks and 83.3%, respectively). Those with complications (18.2%) had a significantly lower RTS rate (90.4%) and longer recovery (23.7 weeks) compared with athletes without complications (97.9% and 14.5 weeks, respectively). Outcomes were not significantly different based on sex or management. However, chronic avulsions and postoperative complications sustained worse RTS results. An accurate and timely diagnosis is crucial when presented with these rare injuries to avoid increasing the chronicity of injury.

Nonoperative Management of Tibial Stress Fractures Result in Higher Return to Sport Rates Despite Increased Failure Versus Operative Management: A Systematic Review.

Purpose: To compare return to sport (RTS) rates and complications after nonoperative versus operative management of tibial stress fractures. Methods: A literature search was conducted per the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using EMBASE, PubMed, and Scopus computerized data from database inception to February 2023. Studies evaluating RTS sport rates and complications after nonoperative or operative management of tibial stress fractures were included. Failure was defined as defined by persistent stress fracture line seen on radiographic imaging. Study quality was assessed using the Modified Coleman Methodology Score. Results: Twenty-two studies consisting of 341 patients were identified. The overall RTS rate ranged from 91.2% to 100% in the nonoperative group and 75.5% to 100% in the operative group. Failures rates ranged from 0% to 25% in the nonoperative groups and 0% to 6% in the operative group. Reoperations were reported in 0% to 6.1% of patients in the operative group, whereas 0% to 12.5% of patients initially managed nonoperatively eventually required operative treatment. Conclusions: Patients can expect high RTS rates after appropriate nonoperative and operative management of tibial stress fractures. Treatment failure rates were greater in patients undergoing nonoperative management, with up to 12.5% initially treated nonoperatively later undergoing operative treatment. Level of Evidence: Level IV; Systematic Review of level I-IV studies.

Radiofrequency Chondroplasty of the Knee Yields Excellent Clinical Outcomes and Minimal Complications: A Systematic Review.

Purpose: To evaluate reported clinical outcomes and complications following radiofrequency (RF) ablation for the treatment of knee chondral lesions. Methods: A literature search was performed according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines by querying EMBASE, PubMed, and Scopus computerized databases from database inception through October 2022. Level I to IV clinical studies that reported outcomes or complications following RF-based chondroplasty were included. Postoperative outcome scores and complications were aggregated. Study quality was assessed via the Newcastle-Ottawa Scale. Results: Ten articles from 2002 to 2018 consisting of 1,107 patients (n = 1,504 lesions) were identified. Four studies were of Level I evidence, 3 studies were Level II, 1 study was Level III, and 2 studies were Level IV. The mean patient age was 41.8 ± 6.3 years (range, 12-87). Seven studies (n = 1,037 patients) used bipolar RF devices, and 3 studies (n = 70 patients) used monopolar RF devices. The overall mean postoperative Lysholm, Tegner, and IKDC scores ranged from 83 to 91, 3.8 to 7, and 49 to 90, respectively, in lesions ranging from grade I-IV according to the Outerbridge Classification. Monopolar RF devices reported qualitatively similar mean changes in Lysholm scores (83), Tegner scores (3.8), and IKDC scores (range, 49-69) compared with bipolar RF devices (range, 86.4-91, 4.5-7, 90, respectively). The incidence of complications ranged from 0% to 4%. The most commonly reported complication was osteonecrosis (range, 0% to 4%). The incidence rate of patients undergoing additional surgery ranged from 0% to 4.5%. Conclusions: The available literature on RF-based chondroplasty shows its efficacy and safety for the treatment of knee chondral lesions, with good clinical outcome scores and low complication and reoperation rates. Level of Evidence: Level IV, systematic review of Level I-IV studies.

Social Media Use Among Arthroscopic and Orthopaedic Sports Medicine Specialists Varies by Subspeciality.

Purpose: To evaluate active social media use among members of the Arthroscopy Association of North America (AANA) and investigate differences in social media use based on joint-specific subspecialization. Methods: The AANA membership directory was queried to identify all active, residency-trained orthopaedic surgeons within the United States. Sex, practice location, and academic degrees earned were recorded. Google searches were conducted to find professional Facebook, Twitter, Instagram, LinkedIn, and YouTube accounts along with institutional and personal websites. The primary outcome was the Social Media Index (SMI) score, an aggregate measure of social media use across key platforms. A Poisson regression model was constructed to compare SMI scores across joint-specific subspecializations: knee, hip, shoulder, elbow, foot & ankle, and wrist. Specialization in the treatment of each joint was collected using binary indicator variables. Since surgeons were specialized in multiple groups, comparisons were made between those who do and do not treat each joint. Results: In total, 2,573 surgeons within the United States met the inclusion criteria. 64.7% had ownership of at least 1 active account, with an average SMI score of 2.29 ± 1.59. Western practicing surgeons had a significantly greater presence on at least 1 website than those in the Northeast (P = .003, P < .001) and South (P = .005, P = .002). Social media use by knee, hip, shoulder, and elbow surgeons was greater relative to those who did not treat those respective joints (P < .001 for all). Poisson regression analysis demonstrated that knee, shoulder, or wrist specialization was a significant positive predictor of a greater SMI score (P ≤ .001 for all). Foot & ankle specialization was a negative predictor (P < .001), whereas hip (P = .125) and elbow (P = .077) were not significant predictors. Conclusions: Social media use widely varies across joint subspecialties within orthopaedic sports medicine. Knee and shoulder surgeons had a greater social media use than their counterparts, whereas foot & ankle surgeons had the lowest social media use. Clinical Relevance: Social media is a vital source of information for both patients and surgeons, providing a means for marketing, networking, and education. It is important to identify variations in social media use by orthopaedic surgeons by subspecialty and explore the differences.

Increasing Telehealth Access to Care for Older Adults During the COVID-19 Pandemic at an Academic Medical Center: Video Visits for Elders Project (VVEP).

BACKGROUND: The COVID-19 pandemic led to a significant increase in ambulatory virtual care, threatening access to care for older adults with lower digital literacy. This report describes the Video Visits for Elders Project (VVEP), a quality improvement effort to help older adults access video visits at an academic primary care practice. METHODS: We reached out to empaneled older adults (≥ 65 years) who had a scheduled visit between March 30 and June 12, 2020. We assessed patients' readiness to engage in a virtual visit and offered to walk them through accessing the platform if they owned a compatible device. We evaluated outcomes of those phone calls and actual visit completion. RESULTS: Between March 26 and June 3, 2020, we called 1,427 patients, reaching 1,025 (71.8%). Of those reached (mean age 75.6 years), 312 (30.4%) were already video-enabled, 192 (18.7%) asked for technical assistance, 185 (18.0%) did not have access to an electronic device, and 336 (32.8%) declined assistance. Of those reached, 40.4% completed their visit by video, 26.5% by telephone, and 1.4% by in-person visit, while 29.6% canceled and 2.1% no-showed. CONCLUSION: VVEP successfully innovated to promote equitable access to telemedicine for vulnerable older patients in a time of crisis. Almost half required technical assistance or did not have access to a compatible device to engage in virtual care. As telemedicine will continue to play an important role in access to clinical care even in a postpandemic world, it is imperative for health systems to focus on technological need to promote equitable access to care for all patients.

Injury to the Posterior Horn of the Lateral Meniscus from a Misplaced Tibial Tunnel for Anterior Cruciate Ligament Reconstruction: A Case Report.

BACKGROUND Posterior meniscal root avulsions can cause meniscal extrusion, joint space narrowing, and progressive knee arthritis. Iatrogenic posterior meniscal root avulsions after malpositioning of the transtibial tunnels during anterior cruciate ligament (ACL) reconstruction can account for poor long-term outcomes seen in some patients following ACL reconstruction. Therefore, correct transtibial tunnel placement during ACL reconstruction is essential to avoid iatrogenic meniscal damage. CASE REPORT A 32-year-old man presented with 1 year of right knee pain and instability following a non-contact twisting injury sustained while playing soccer. An ACL tear with no meniscal involvement was diagnosed at an outside institution. A double-bundle reconstruction was performed at that time. Three months after surgery, a medial partial meniscectomy was performed after a medial meniscal tear and failure to reduce initial symptoms during the index procedure. Advanced imaging at our institution 6 months later demonstrated an iatrogenic lateral posterior meniscal root avulsions after malpositioning of the transtibial tunnels. Given the ACL graft integrity upon arthroscopic evaluation, the root tear was repaired using a 2-tunnel transtibial pull-out technique. Advanced imaging 1 year after surgery showed a well-maintained meniscal repair with no extrusion. CONCLUSIONS Accurate transtibial tunnel placement during ACL reconstructive surgery is vital to avoid meniscal root detachment and the associated complications resulting in poor patient outcomes from this iatrogenic injury. Clinicians treating patients with a history of cruciate ligament reconstruction presenting with postoperative pain and instability should consider this pathology in their differential diagnosis.

Technique Articles Are More Effective at Increasing Social Media Attention in Comparison With Original Research Articles: An Altmetrics-Based Analysis.

Purpose: To compare social media attention and citation rates between technique articles and matched original research articles (ORAs) regarding surgical procedures. Methods: All technique articles published from August 2019 through July 2020 in the free, electronic versions of Arthroscopy Techniques and JBJS Essential Surgical Techniques were matched by topic to articles in the "Original Research" sections of Arthroscopy, Sports Medicine, and Rehabilitation and JBJS Open Access in a 4:1 ratio within this time frame. The primary outcome was the Altmetric Attention Score (AAS). Secondary outcomes included citations, bibliometrics, and social media metrics. Independent t tests were used to compare primary and secondary outcomes between technique articles and ORAs. A multivariate linear regression analysis was performed to determine the association between article type and social media attention while controlling for confounding bibliometric characteristics. Results: A total of 285 matched research articles (n = 57, 20.0%) and technique articles (n = 228, 80.0%) were included. The mean AAS among all technique articles was 3.63 ± 10.08 (range, 0-96) whereas the mean AAS among all ORAs was 1.30 ± 3.98 (range, 0-25), representing a statistically significant difference (P = .016). The mean citation rate among all technique articles was not significantly different from that among ORAs (P = .73). Multivariate linear regression analysis showed a statistically significant positive association between AAS and article type, with an additional mean increase in the AAS of 2.91 (95% confidence interval, 0.04-5.77; P = .047) for every technique article compared with an ORA. Furthermore, a significant positive relation was noted between the article origin and the AAS, with an increase in the AAS of 3.00 (95% confidence interval, 0.82-5.17; P = .007) for every article published in North America compared with an article originating from another continent. Conclusions: Technique articles resulted in significantly greater AASs and social media attention in comparison with open-access ORAs on similar topics. Publications that described technical procedures in a technique journal and studies from North America were positively associated with greater AASs and greater numbers of citations received by articles. Clinical Relevance: An improved understanding of how much attention is given to technique articles versus matched ORAs by social media may influence the methods authors and journals use for distributing content. The present study suggests that one option to increase the amount of social media attention received for a particular study may be to utilize an accompanying surgical technique video or illustrations as these are easily shareable on social media and offer rapid dissemination of knowledge, similar to that of an infographic. However, physicians who view multimedia within technique articles should be encouraged to review the accompanying articles and the supporting original research as a primary source before making changes in their clinical practice.

Open Access Articles Garner Increased Social Media Attention and Citation Rates Compared With Subscription Access Research Articles: An Altmetrics-Based Analysis.

BACKGROUND: To better understand the research impact on social media, alternative web-based metrics (Altmetrics) were developed. Open access (OA) publishing, which allows for widespread distribution of scientific content, has become increasingly common in the medical literature. However, the relationship between OA publishing and social media impact remains unclear. PURPOSE: To compare social media attention and citation rates between OA and subscription access (SA) research articles within the orthopaedic and sports medicine literature. STUDY DESIGN: Cross-sectional study. METHODS: Articles published as either OA or SA in 5 high-impact hybrid orthopaedic journals between January 2019 and December 2019 were analyzed. The primary outcome was the Altmetric Attention Score (AAS), a validated measure of social media attention. Secondary outcomes included citation rates, article characteristics, and the number of shares on social media. Independent t tests and chi-square analyses were used to compare outcomes between OA and SA articles. A multivariable linear regression analysis was performed to determine the association between article type and AAS while controlling for bibliometric characteristics. RESULTS: A total of 2143 articles (246 OA articles, 11.5%; 1897 SA articles, 88.5%) were included. The mean AAS among all OA articles was 62.4 ± 184.6 (range, 0-2032), whereas the mean AAS among all SA articles was 18.4 ± 109.8 (range, 0-3425), representing a statistically significant difference (P < .001). The mean citation rate among OA articles was significantly higher (17.0 ± 22.5; range, 0-139) than that of SA articles (8.6 ± 13.4; range, 0-169) (P < .001). Multivariable linear regression analysis demonstrated that OA status (ß = 15.15; P = .044), number of institutions (ß = 2.13; P = .023), studies classified as epidemiological investigations (ß = 107.40; P < .001), and disclosure of a conflict of interest (ß = -11.18; P = .032) were significantly associated with a higher AAS. CONCLUSION: OA articles resulted in significantly greater AAS and citations in comparison with SA articles. Articles published through the OA option in hybrid journals as well as those with a higher number of institutions, those that disclosed a conflict of interest, and those classified as epidemiological investigations were positively associated with greater AAS in addition to a greater number of citations. The potential for more extensive research dissemination inherent in the OA option may therefore translate into greater reach and social media attention.