Current Implementation of Quality Measures on American Society for Surgery of the Hand Touching Hands Project Outreach Trips.

PURPOSE: As hand and upper extremity outreach trips increase, guidelines for assessing quality of care are being established. The Global Quality in Upper Extremity Surgery and Training investigators have published validated quality measures deemed to be essential for outreach trips to low and middle-income countries (LMICs). The purpose of this study was to assess baseline implementation of these quality measures across nine international hand surgery outreach sites to LMICs. Additionally, we investigated barriers and facilitators to implementing quality measures and documentation of their implementation. METHODS: We included nine of 12 scheduled 2019 Touching Hands Project trips, excluding independent outreach and teaching mission trips without surgical logs. The team leader from each site received an online questionnaire assessing the documentation and implementation of all 22 quality measures, as well as educational efforts. RESULTS: A total of 350 surgeries were performed in 2019 with seven reported minor complications and no major complications or mortalities. For analysis, 20 of 22 quality measures were included. Of 20 included validated quality measures, 10 were implemented across all surgical outreach sites. Two sites (Bolivia, Nepal) implemented all of the validated quality measures. Quality measures with the lowest implementation rates included ensuring availability of continuous electricity and oxygen supply with associated documentation of a backup plan. All outreach sites reported formal educational efforts. CONCLUSIONS: Implementation of validated quality measures across surveyed outreach sites is variable, indicating an opportunity for improvement. Standardizing documentation of quality measure implementation for each site, confirming availability of resources, increasing accountability by the visiting teams, and fostering stronger relationships with local health care, may increase quality measure implementation and improve quality health care delivery and patient safety in LMICs. CLINICAL RELEVANCE: Benchmarking the implementation of validated quality measures across hand surgical outreach trips provides an opportunity to improve the quality of health care delivered during future hand surgical outreach efforts.

Evaluation of Racial, Ethnic, and Socioeconomic Disparities in Indication for Carpal Tunnel Release.

BACKGROUND: Disparities in the utilization of orthopaedic surgery based on race and ethnicity continue to be reported. We examined the impact of sociodemographic factors on treatment recommendation by hand surgeons for carpal tunnel syndrome (CTS) of similar disease severity. METHODS: Patients with electrodiagnostic study (EDS)-confirmed CTS were evaluated at a single institution between 2016 and 2020. Data including patient age, sex, race/ethnicity, ZIP Code, and EDS severity were collected. The primary outcome was the recommended treatment by the hand surgeon at the first clinic visit according to patient race/ethnicity and the Social Deprivation Index (SDI). Secondary outcomes included the treatment selected by patients (nonsurgical or surgical) and the time to surgery. RESULTS: The 949 patients had a mean age of 58 years (range, 18 to 80 years); 60.5% (n = 574) were women. The race/ethnicity of the patient cohort was 9.8% (n = 93) Black non-Hispanic, 11.2% (n = 106) Hispanic/Latino, 70.3% (n = 667) White non-Hispanic, and 8.7% (n = 83) "other." Overall, Black non-Hispanic patients (38.7%; odds ratio, [OR] 0.62; 95% confidence interval [CI], 0.40 to 0.96) and Hispanic/Latino patients (35.8%; OR, 0.55; 95% CI, 0.36 to 0.84) were less likely to have surgery recommended at their first visit compared with White non-Hispanic patients (50.5%). This was no longer apparent after adjusting for demographic and clinical variables including EDS severity and SDI (Black non-Hispanic patients: adjusted odds ratio [aOR], 0.67; 95% CI, 0.4 to 1.11; Hispanic/Latino patients: aOR, 0.69: 95% CI, 0.41 to 1.14). Across all categories of EDS severity, surgeons were less likely to recommend surgery to patients with a higher SDI (aOR: 0.66, 0.64, and 0.54 for quintiles 2, 3 and 4, respectively). When surgery was recommended, patients in the highest SDI quintile were less likely to proceed with surgery (p = 0.032). There was no association between patient race/ethnicity and the treatment selected by the patient or time to surgery (p = 0.303 and p = 0.725, respectively). CONCLUSIONS: Patients experiencing higher levels of social deprivation were less likely to be recommended for CTS surgery and were less likely to proceed with surgery, regardless of patient race/ethnicity. Additional investigation into the social factors influencing both surgeon and patient selection of treatment for CTS, including the impact of patient socioeconomic background, is warranted. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Teaching in Orthopaedic Surgery: Effective Strategies for Educating the Modern Learner in a Modern Surgical Practice.

Prioritizing the education of orthopaedic surgery residents and fellows is essential for the future of the field. This review highlights strategies that educators may find useful in improving their teaching skills for the modern orthopaedic surgery learner. Educators may benefit from focusing on active, effortful, and repetitive engagement in lecture; setting clear expectations to help track progress in clinic; and breaking skills into smaller steps in context of a framework when teaching procedural skills. Providing objective assessment and growth-oriented feedback helps establish a close rapport between educator and trainee while encouraging personal development. Through a remediation process that examines deficiency in core areas and equitability of the learning environment, the trainee and the educator may engage in a fair discussion that prevents trainees from falling behind. Finally, in the era of COVID-19, e-learning and virtual simulations have become increasingly used as effective modalities for teaching clinical knowledge and procedures to trainees. The medical education landscape has been changing at a rapid pace, and by evaluating and adapting to the novel educational models of today, the modern orthopaedic surgeon ensures a learning environment that is equitable, effective, and inspiring for the orthopaedic surgeon of tomorrow.

Fibrillar pharmacology of functionalized nanocellulose.

Cellulose nanocrystals (CNC) are linear organic nanomaterials derived from an abundant naturally occurring biopolymer resource. Strategic modification of the primary and secondary hydroxyl groups on the CNC introduces amine and iodine group substitution, respectively. The amine groups (0.285 mmol of amine per gram of functionalized CNC (fCNC)) are further reacted with radiometal loaded-chelates or fluorescent dyes as tracers to evaluate the pharmacokinetic profile of the fCNC in vivo. In this way, these nanoscale macromolecules can be covalently functionalized and yield water-soluble and biocompatible fibrillar nanoplatforms for gene, drug and radionuclide delivery in vivo. Transmission electron microscopy of fCNC reveals a length of 162.4 ± 16.3 nm, diameter of 11.2 ± 1.52 nm and aspect ratio of 16.4 ± 1.94 per particle (mean ± SEM) and is confirmed using atomic force microscopy. Size exclusion chromatography of macromolecular fCNC describes a fibrillar molecular behavior as evidenced by retention times typical of late eluting small molecules and functionalized carbon nanotubes. In vivo, greater than 50% of intravenously injected radiolabeled fCNC is excreted in the urine within 1 h post administration and is consistent with the pharmacological profile observed for other rigid, high aspect ratio macromolecules. Tissue distribution of fCNC shows accumulation in kidneys, liver, and spleen (14.6 ± 6.0; 6.1 ± 2.6; and 7.7 ± 1.4% of the injected activity per gram of tissue, respectively) at 72 h post-administration. Confocal fluorescence microscopy reveals cell-specific accumulation in these target tissue sinks. In summary, our findings suggest that functionalized nanocellulose can be used as a potential drug delivery platform for the kidneys.

Patterns of Articular Cartilage Thickness in Pediatric and Adolescent Knees: A Magnetic Resonance Imaging-Based Study.

PURPOSE: To establish normative values for articular cartilage thickness in pediatric and adolescent knees using magnetic resonance imaging (MRI) and investigate for any associations with age and skeletal maturity. METHODS: MRI scans were analyzed in patients 7 to 18 years old without osteochondral lesions, chondral wear/pathology, intra-articular fractures, or history of knee surgery. Measurements of articular cartilage thickness at the patella (medial facet, lateral facet, median ridge), femur (medial condyle, lateral condyle, lateral trochlea), and tibia (medial plateau, lateral plateau) were made on axial, coronal, and sagittal MRI. Descriptive statistics were used to calculate mean cartilage thickness by age and sex. Analysis of variance with repeated measures, analysis of covariance, independent samples t test, and linear regression were performed to determine differences in mean cartilage thickness by anatomic location, sex, physeal status, and age, respectively. RESULTS: A total of 240 knee MRI scans were included. Articular cartilage was thickest at the patella and did not vary with age or skeletal maturity. On the femur, articular cartilage was thickest at the lateral trochlea with mean cartilage thickness of 4.4 ± 1.4 mm in male patients and 3.6 ± 1.3 mm in female patients (P < .001). Patients with open distal femoral physes had significantly thicker cartilage at the medial femoral condyle, lateral femoral condyle, and lateral trochlea compared to patients with closing/closed physes (P < .001). Linear regression analysis revealed a significant inverse association between cartilage thickness at the femur and age. CONCLUSIONS: In pediatric and adolescent knees, articular cartilage is thickest at the patella, where it does not strongly correlate with age. In contrast, there is a strong inverse association between increasing age and articular cartilage thickness of the distal femoral condyles. CLINICAL RELEVANCE: The longitudinal reference data presented in this study can aid in pre-operative interpretation of knee cartilage under pathologic conditions in pediatric and adolescent patients.

A Genomic Profile of Local Immunity in the Melanoma Microenvironment Following Treatment with α Particle-Emitting Ultrasmall Silica Nanoparticles.

An α particle-emitting nanodrug that is a potent and specific antitumor agent and also prompts significant remodeling of local immunity in the tumor microenvironment (TME) has been developed and may impact the treatment of melanoma. Biocompatible ultrasmall fluorescent core-shell silica nanoparticles (C' dots, diameter ∼6.0 nm) have been engineered to target the melanocortin-1 receptor expressed on melanoma through α melanocyte-stimulating hormone peptides attached to the C' dot surface. Actinium-225 is also bound to the nanoparticle to deliver a densely ionizing dose of high-energy α particles to cancer. Nanodrug pharmacokinetic properties are optimal for targeted radionuclide therapy as they exhibit rapid blood clearance, tumor-specific accumulation, minimal off-target localization, and renal elimination. Potent and specific tumor control, arising from the α particles, was observed in a syngeneic animal model of melanoma. Surprisingly, the C' dot component of this drug initiates a favorable pseudopathogenic response in the TME generating distinct changes in the fractions of naive and activated CD8 T cells, Th1 and regulatory T cells, immature dendritic cells, monocytes, MΦ and M1 macrophages, and activated natural killer cells. Concomitant upregulation of the inflammatory cytokine genome and adaptive immune pathways each describes a macrophage-initiated pseudoresponse to a viral-shaped pathogen. This study suggests that therapeutic α-particle irradiation of melanoma using ultrasmall functionalized core-shell silica nanoparticles potently kills tumor cells, and at the same time initiates a distinct immune response in the TME.

Carbon nanotubes exhibit fibrillar pharmacology in primates.

Nanomedicine rests at the nexus of medicine, bioengineering, and biology with great potential for improving health through innovation and development of new drugs and devices. Carbon nanotubes are an example of a fibrillar nanomaterial poised to translate into medical practice. The leading candidate material in this class is ammonium-functionalized carbon nanotubes (fCNT) that exhibits unexpected pharmacological behavior in vivo with important biotechnology applications. Here, we provide a multi-organ evaluation of the distribution, uptake and processing of fCNT in nonhuman primates using quantitative whole body positron emission tomography (PET), compartmental modeling of pharmacokinetic data, serum biomarkers and ex vivo pathology investigation. Kidney and liver are the two major organ systems that accumulate and excrete [86Y]fCNT in nonhuman primates and accumulation is cell specific as described by compartmental modeling analyses of the quantitative PET data. A serial two-compartment model explains renal processing of tracer-labeled fCNT; hepatic data fits a parallel two-compartment model. These modeling data also reveal significant elimination of the injected activity (>99.8%) from the primate within 3 days (t1/2 = 11.9 hours). These favorable results in nonhuman primates provide important insight to the fate of fCNT in vivo and pave the way to further engineering design considerations for sophisticated nanomedicines to aid late stage development and clinical use in man.