Hold the Antibiotics: Are Preoperative Antibiotics Unnecessary in the Treatment of Pediatric Supracondylar Humerus Fractures?

BACKGROUND

Supracondylar humerus (SCH) fracture is the most common elbow injury in children and often treated with closed reduction and percutaneous pinning (CRPP). There is little published evidence supporting or refuting the use of perioperative prophylactic antibiotics for SCH CRPP in the pediatric population. The purpose of this study is to evaluate the rate of surgical site infection for patients with and without preoperative antibiotics.

METHODS

A retrospective chart review was conducted of patients less than or equal to 16 years from 2012 to 2018 who underwent primary CRPP. Open fractures, multilimbed polytraumas, and immunodeficient patients were excluded. Infection rates were compared using a noninferiority test assuming a 3% infection rate and a predefined noninferiority margin of 4%. A total of 255 patients were needed to adequately power the study.

RESULTS

Of the 1253 cases identified, 845 met eligibility criteria. A total of 337 received antibiotics, and 508 did not. Preoperative nerve injury (P=0.0244) and sterilization technique (P<0.0001) were associated with antibiotic use: 4 patients developed an infection; there were successfully treated superficial infections, and 1 was a deep infection requiring a formal debridement. There were 8 patients that had a recorded mal-union, and 6 patients required additional procedures; 1 patient had a postoperative compartment syndrome on postoperation day 1. The infection rates among patients treated with and without antibiotics were 0.60% and 0.40%, respectively. The absence of antibiotics was not clinically inferior to using antibiotics (P=0.003).

CONCLUSIONS

Infection remains a rare complication following CRPP of SCH fractures. According to our current data, not giving perioperative antibiotics was not inferior to using perioperative antibiotics for preventing superficial or deep infection in patients undergoing CRPP of SCH fractures. With the increase in attention to antibiotic stewardship, it is important to eliminate unnecessary antibiotic use while continuing to maintain a low rate of surgical site infection.

LEVEL OF EVIDENCE

Level IV-case series. This is a therapeutic study that investigates the results from a case series.

Resident Education and Wellness: A Strategy for Future Pandemics

The Coronavirus Disease 2019 (COVID-19) pandemic presented a novel challenge to modern healthcare systems and medical training. Resource allocation and risk mitigation dramatically affected resident training. The objective of this article is to develop new strategies to maintain a healthy, competent residency program while combating the unique challenges to resident education and wellness. In 2020, our institution implemented a revolving 3-Team system. While the "Inpatient-Team" delivered direct care, the "Back-up Team" and "Quarantine-Team" managed the telemedicine virtual clinic and education-wellness strategy, respectively. Our 3-Team system allowed delivery of safe, high-quality patient care while optimizing resident education, research, and wellness. The efficient use of technology led to both improved virtual education outside of the hospital and intentional wellness opportunities despite social distancing restrictions. Utilization of virtual platforms for patient care, education, research, and wellness grew out of necessity in this pandemic, yet represent an opportunity for lasting improvement. (Journal of Surgical Orthopaedic Advances 31(3):150-154, 2022).

COVID-19: Impact on Orthopaedic Graduate Medical Education in the U.S.: AOA Critical Issues Symposium

The COVID-19 crisis has challenged the U.S. health-care system in a variety of ways, including how we teach and train orthopaedic surgery residents and fellows. During the spring of 2020, the cessation of all elective surgical procedures and the diminished number of outpatient visits challenged graduate medical education. While residency programs in less affected areas may not have had to make many dramatic adjustments, some of those located in pandemic hotspots had to redirect trainees from orthopaedic rotations to COVID-19 units. No matter the region, the time that trainees have spent in rotations has been altered, and absences have occurred due to quarantines. This symposium summarizes the impact of restrictions related to the COVID-19 pandemic on residency and fellowship programs from the perspectives of the Accreditation Council for Graduate Medical Education (ACGME), a program director, and a graduating resident. Although new opportunities for virtual curricula, virtual surgical simulation, and virtual interviews have been innovated, residency programs and residents report primarily a negative effect from the pandemic due to decreased surgical volumes and the limitation of patient-care experiences. Ultimately, program directors have an obligation to the program, the trainee, and the general public to graduate only those residents and fellows who are truly prepared to practice independently; they have the responsibility of making the final decision regarding graduation. The COVID-19 pandemic has continued to underscore the need for competency-based medical education. Assessing competency includes evaluation of the knowledge, the operative skills, the nonoperative patient-care skills, and the professional behavior of each and every individual graduating from orthopaedic residency and fellowship training programs. A hybrid model for time and competency-based training, with established national standards not only for accreditation for our training programs but also for board certification of our graduating residents, was enhanced by the COVID-19 pandemic and is highlighted in this symposium.

Can a Clinician-Scientist Training Program Develop Academic Orthopaedic Surgeons? One Program's Thirty-Year Experience

BACKGROUND

Clinician-scientist numbers have been stagnant over the past few decades despite awareness of this trend. Interventions attempting to change this problem have been seemingly ineffective, but research residency positions have shown potential benefit.

OBJECTIVE

We sought to evaluate the effectiveness of a clinician-scientist training program (CSTP) in an academic orthopedic residency in improving academic productivity and increasing interest in academic careers.

METHODS

Resident training records were identified and reviewed for all residents who completed training between 1976 and 2014 (n = 329). There were no designated research residents prior to 1984 (pre-CSTP). Between 1984 and 2005, residents self-selected for the program (CSTP-SS). In 2005, residents were selected by program before residency (CSTP-PS). Residents were also grouped by program participation, research vs. clinical residents (RR vs. CR). Data were collected on academic positions and productivity through Internet-based and PubMed search, as well as direct e-mail or phone contact. Variables were then compared based on the time duration and designation.

RESULTS

Comparing all RR with CR, RR residents were more likely to enter academic practice after training (RR, 34%; CR, 20%; p = 0.0001) and were 4 times more productive based on median publications (RR, 14; CR, 4; p < 0.0001). Furthermore, 42% of RR are still active in research compared to 29% of CR (p = 0.04), but no statistical difference in postgraduate academic productivity identified.

CONCLUSIONS

The CSTP increased academic productivity during residency for the residents and the program. However, this program did not lead to a clear increase in academic productivity after residency and did not result in more trainees choosing a career as clinician-scientists.

Human IL6 stimulates bovine satellite cell proliferation through a Signal transducer and activator of transcription 3 (STAT3)-dependent mechanism

Bovine satellite cell (bSC) myogenesis and skeletal muscle hypertrophy occur through the orchestrated actions of multiple autocrine and paracrine growth factors. Intimate to the bSC niche is IL6, a dual-purpose cytokine with proinflammatory and mitogenic properties. The objective of the experiment was to examine the effects of IL6 on proliferation and differentiation of bSC in vitro. Treatment of primary bSC cultures with recombinant bovine IL6 (bIL6) failed to alter myogenesis owing to the absence of intracellular signal transduction. The cytokine was able to stimulate phosphorylation of signal transducer and activator of transcription 3 tyrosine 705 (STAT3^Y705) in Madin-Darby bovine kidney (MDBK) epithelial cells, thus demonstrating bioactivity. Media supplemented with recombinant human IL6 (hIL6) caused phosphorylation of STAT3^Y705 in bSC and increased (P < 0.05) proliferation. Inclusion of a STAT3 inhibitor in the media blunted phosphorylation of the STAT3^Y705 and suppressed (P < 0.05) hIL6-mediated bSC proliferation. Morphologic and biochemical measures of bSC differentiation remained unchanged (P > 0.05) following treatment for 48 h with hIL6. These results support a role for hIL6 as a bSC mitogen in vitro. The inability of bIL6 to initiate an intracellular signal in bSC requires further investigation.

The effect of discharge disposition on 30-day readmission rates after total joint arthroplasty

Previous studies have demonstrated no significant difference in overall functional outcomes of patients discharged to a sub acute setting versus home with health services after total joint arthroplasty. These findings coupled with pressure to reduce health care costs and the implementation of a prospective payment system under Medicare have supported the use of home rehabilitation services and the trend towards earlier discharge after hospitalization. While the overall functional outcome of patients discharged to various settings has been studied, there is a relative dearth of investigation comparing postoperative complications and readmission rates between various discharge dispositions. Our study demonstrated patients discharged home with health services had a significantly lower 30 day readmission rate compared to those discharged to inpatient rehab facilities. Patients discharged to rehab facilities have a higher incidence of comorbidity and this association could be responsible for their higher rate of readmission.

Antagonism and accommodation: interpreting the relationship between public health and medicine in the United States during the 20th century

Throughout the course of the 20th century, many observers have noted important tensions and antipathies between public health and medicine. At the same time, reformers have often called for better engagement and collaboration between the 2 fields. This article examines the history of the relationship between medicine and public health to examine how they developed as separate and often conflicting professions. The historical character of this relationship can be understood only in the context of institutional developments in professional education, the rise of the biomedical model of disease, and the epidemiologic transition from infectious disease to the predominance of systemic chronic diseases. Many problems in the contemporary burden of disease pose opportunities for effective collaborations between population-based and clinical interventions. A stronger alliance between public health and medicine through accommodation to a reductionist biomedicine, however, threatens to subvert public health's historical commitment to understanding and addressing the social roots of disease.

Electronic patient-physician communication: problems and promise

A critical mass of Internet users will soon enable wide diffusion of electronic communication within medical practice. E-mail between physicians and patients offers important opportunities for better communication. Linking patients and physicians through e-mail may increase the involvement of patients in supervising and documenting their own health care, processes that may activate patients and contribute to improved health. These new linkages may have profound implications for the patient-physician relationship. Although the federal government proposes regulation of telemedicine technologies and medical software, communications technologies are evolving under less scrutiny. Unless these technologies are implemented with substantial forethought, they may disturb delicate balances in the patient-physician relationship, widen social disparities in health outcomes, and create barriers to access to health care. This paper seeks to identify the promise and pitfalls of electronic patient-physician communication before such technology becomes widely distributed. A research agenda is proposed that would provide data that are useful for careful shaping of the communications infrastructure. The paper addresses the need to 1) define appropriate use of the various modes of patient-physician communication, 2) ensure the security and confidentiality of patient information, 3) create user interfaces that guide patients in effective use of the technology, 4) proactively assess medicolegal liability, and 5) ensure access to the technology by a multicultural, multilingual population with varying degrees of literacy.

FDA regulation of tobacco advertising and youth smoking. Historical, social, and constitutional perspectives

Perspectives on tobacco control in American society have shifted markedly. As the view that smoking as a voluntarily assumed health risk has declined, the social and political environment has become more conducive to industry regulation. This transformation can be traced to the mounting evidence of the health risks of secondary smoke; the addictive quality of nicotine; the vulnerability and exploitation of young people; and industry knowledge of the harmful effects of tobacco. Regulation of tobacco advertising and promotions by the Food and Drug Administration (FDA) raises serious concerns about constitutional protection for commercial speech. However, the minimal informational value of tobacco advertising suggests that it should be afforded a low level of constitutional protection. The FDA regulations impose reasonable "time, place, and manner" restrictions, leave open alternative channels of communication, restrict messages that are harmful to the public health, do not restrict political speech, prevent misleading messages, and help deter the unlawful sale of tobacco products to minors. The regulations meet the traditional criteria for regulating commercial speech, in that the government's asserted interest is strong, the agency's regulations directly advance that interest, and the regulations are no more extensive than necessary. Thus, the judiciary should defend the FDA's historical social and legislative mission to protect the public health.

Recruiting women smokers: the engineering of consent

A range of social forces contributed to the effective recruitment of women to cigarette smoking in the crucial period between 1900 and 1940. Cigarette advertisers and public relations experts recognized the significance of women's changing roles and the rising culture of consumption, and worked to create specific meanings for the cigarette to make it appeal to women. The cigarette was a flexible symbol, with a remarkably elastic set of meanings; for women, it represented rebellious independence, glamour, seduction, and sexual allure, and served as a symbol for both feminists and flappers. The industry, with the help of advertisers and public relations experts, effectively engineered consent for women as smokers. The "engineering of consent" has a role to play in smoking cessation, since negative meanings for the cigarette can be engineered as well.

The syphilis epidemic and its relation to AIDS

This article presents an overview of the history of medical and public health responses to syphilis in the 20th-century United States and briefly evaluates the relevance and significance of these approaches for the AIDS epidemic. The parallels are numerous: they relate to science, public health, civil liberties, and social attitudes concerning sexually transmitted infection. The strengths and limits of past approaches to controlling sexually transmitted diseases are explored as a possible guide for AIDS policy.

Compulsory premarital screening for the human immunodeficiency virus. Technical and public health considerations

The effectiveness of a mandatory premarital screening program was examined as a means of curtailing the spread of the human immunodeficiency virus (HIV) infection in the United States. The epidemiology of the HIV, the technical characteristics of tests for antibodies to HIV, and the logistic, economic, and legal implications of such a program were considered. In one year, universal premarital screening in the United States currently would detect fewer than one tenth of 1% of HIV-infected individuals at a cost of substantially more than +100 million. More than 100 infected individuals would be told that they were probably not infected, and there would likely be more than 350 false-positive results. Public education, counseling of individuals, and discretionary testing can be important tools in reducing the spread of HIV infection, but mandatory premarital screening in a population with a low prevalence of infection is a relatively ineffective and inefficient use of resources.

AIDS: from social history to social policy

Despite philosopher George Santayana's famous injunction that those who do not remember the past are condemned to repeat it, history holds no simple truths. Nevertheless, there are a number of significant historical questions relating to the AIDS epidemic. What does the history of medicine and public health have to tell us about contemporary approaches to the very difficult dilemmas raised by AIDS? Is AIDS something totally new, or are there instances in the past that are usefully comparable? Are there some lessons in the way science and society has responded to epidemic disease in the past that could inform our understanding of and response to the current health crisis?

There are obviously no simple answers to such questions. History is not a fable with the moral spelled out at the end. Even if we could agree on a particular construction of past events, it would not necessarily lead to consensus on what is to be done. And yet, history provides us with one means of approaching the present. In this regard, the history of responses to particular diseases can inform and deepen our understanding of the AIDS crisis and the medical, social, and public health interventions available.

Polio, politics, publicity, and duplicity: ethical aspects in the development of the Salk vaccine

This paper is an historical account of the discovery, testing, and early distribution of the Salk polio vaccine. The discovery posed fundamental dilemmas of medical research, pharmaceutical production, and public health. This paper assesses the ethical problems which arose, and examines critically their resolution. The National Foundation for Infantile Paralysis (March of Dimes) financed and directed the discovery of the vaccine, subsequent field trials, and early distribution. The Foundation's role is analyzed with special attention to the conflicts between its philanthropic and scientific functions. The reat public demand which the discovery of the vaccine generated created a need for federal control which was only partly met. The federal government did not have sufficient institutional and legal mechanisms to assure the safety of the vaccine and protect the public. This discussion illustrates the failure of the government to keep pace with medical technology.