Women in trauma and orthopaedics: are we losing them at the first hurdle?

INTRODUCTION

Diversity in the healthcare workforce is associated with improved performance and patient-reported outcomes. Gender disparity in Trauma and Orthopaedics (T&O) is well recognised. The aim of this study was to compare factors that influence career choice in T&O between male and female final-year students. Furthermore, the trend of representation of women in T&O over the last decade was also compared with other surgical specialities.

METHODS

An online survey of final-year students who attended nationally advertised T&O courses over a 2-year period was conducted. Data from NHS digital was obtained to assess gender diversity in T&O compared with other surgical specialities.

RESULTS

A total of 414 students from 13 UK medical schools completed the questionnaire. Compared with male students (34.2%), a significantly higher proportion of women (65.8%) decided against a career in T&O, p<0.001. Factors that dissuaded a significantly higher percentage of women included gender bias, technical aspects of surgery, unsociable hours, on-call commitments, inadequate undergraduate training and interest in another specialty (p<0.05). Motivating factors for choosing a career in T&O were similar between both sexes. T&O was the surgical specialty with the lowest proportion of women at both consultant and trainee level over the last decade.

CONCLUSION

T&O remains an unpopular career choice among women. To enhance recruitment of women in T&O, future strategies should be directed toward medical students. Universities, orthopaedic departments and societies must work collaboratively to embed culture change, improve the delivery of the undergraduate curriculum, and facilitate students' exposure to operating theatres and female role models.

Carbon uptake in Eurasian boreal forests dominates the high-latitude net ecosystem carbon budget

Arctic-boreal landscapes are experiencing profound warming, along with changes in ecosystem moisture status and disturbance from fire. This region is of global importance in terms of carbon feedbacks to climate, yet the sign (sink or source) and magnitude of the Arctic-boreal carbon budget within recent years remains highly uncertain. Here, we provide new estimates of recent (2003-2015) vegetation gross primary productivity (GPP), ecosystem respiration (R_eco ), net ecosystem CO₂ exchange (NEE; R_eco  - GPP), and terrestrial methane (CH₄ ) emissions for the Arctic-boreal zone using a satellite data-driven process-model for northern ecosystems (TCFM-Arctic), calibrated and evaluated using measurements from >60 tower eddy covariance (EC) sites. We used TCFM-Arctic to obtain daily 1-km² flux estimates and annual carbon budgets for the pan-Arctic-boreal region. Across the domain, the model indicated an overall average NEE sink of -850 Tg CO₂ -C year^-1 . Eurasian boreal zones, especially those in Siberia, contributed to a majority of the net sink. In contrast, the tundra biome was relatively carbon neutral (ranging from small sink to source). Regional CH₄ emissions from tundra and boreal wetlands (not accounting for aquatic CH₄ ) were estimated at 35 Tg CH₄ -C year^-1 . Accounting for additional emissions from open water aquatic bodies and from fire, using available estimates from the literature, reduced the total regional NEE sink by 21% and shifted many far northern tundra landscapes, and some boreal forests, to a net carbon source. This assessment, based on in situ observations and models, improves our understanding of the high-latitude carbon status and also indicates a continued need for integrated site-to-regional assessments to monitor the vulnerability of these ecosystems to climate change.

Affimers targeting proteins in the cardiomyocyte Z-disc: Novel tools that improve imaging of heart tissue

Dilated Cardiomyopathy is a common form of heart failure. Determining how this disease affects the structure and organization of cardiomyocytes in the human heart is important in understanding how the heart becomes less effective at contraction. Here we isolated and characterised Affimers (small non-antibody binding proteins) to Z-disc proteins ACTN2 (α-actinin-2), ZASP (also known as LIM domain binding protein 3 or LDB3) and the N-terminal region of the giant protein titin (TTN Z1-Z2). These proteins are known to localise in both the sarcomere Z-discs and the transitional junctions, found close to the intercalated discs that connect adjacent cardiomyocytes. We use cryosections of left ventricles from two patients diagnosed with end-stage Dilated Cardiomyopathy who underwent Orthotopic Heart Transplantation and were whole genome sequenced. We describe how Affimers substantially improve the resolution achieved by confocal and STED microscopy compared to conventional antibodies. We quantified the expression of ACTN2, ZASP and TTN proteins in two patients with dilated cardiomyopathy and compared them with a sex- and age-matched healthy donor. The small size of the Affimer reagents, combined with a small linkage error (the distance from the epitope to the dye label covalently bound to the Affimer) revealed new structural details in Z-discs and intercalated discs in the failing samples. Affimers are thus useful for analysis of changes to cardiomyocyte structure and organisation in diseased hearts.

The impact of mentoring in trauma and orthopaedic training: a systematic review

INTRODUCTION

Trauma and orthopaedics is renowned for being a challenging yet rewarding career. The value of mentorship in medical and surgical training is known to be beneficial; however, the prevalence and quality of mentorship opportunities in orthopaedics are less well studied. Identifying the strengths and weaknesses of mentoring programmes in orthopaedic training and recognising barriers to effective mentorship are key to unlocking the full potential of future orthopaedic surgeons.

METHODS

A comprehensive search of PubMed, Medline, EMBASE and the Cochrane Library was performed. All studies published in the English language that reported data on mentorship programmes in orthopaedic training were included.

FINDINGS

A total of 23 studies met the inclusion criteria. These studies demonstrated that formal mentorship programmes in orthopaedics are lacking but are sought after, with a positive influence on satisfaction and future career choice/subspecialty selection identified. Several barriers to mentoring in the field were recognised including the difficulty faced by female trainees, the availability of mentors and time constraints. The opportunity to choose a mentor, a mentor with the same interests, regular meetings and the option of gender congruent mentorship were all identified as crucial requirements for effective mentorship.

CONCLUSION

Mentorship opportunities must be more accessible to all orthopaedic trainees alike and should aim to incorporate the attributes identified to provide the highest calibre of training to prospective orthopaedic surgeons.

Release of individual surgeon data to the public: patients' and surgeons' views

BACKGROUND

Limited surgeon-specific outcomes data are currently released to the public. Existing schemes generally result from the recommendations of public enquiries, addressing breaches to patient safety and malpractice. We found limited evidence in the literature about patients' or orthopaedic surgeons' wishes regarding the release of such data to the public.

METHODS

We surveyed 80 joint replacement patients and 41 orthopaedic surgeons regarding their wishes concerning collection and release of individual surgeon data to the public.

RESULTS

Of 80 patients, 30% (24/80) were aware of data on the NHS-My Choices website, 16% (13/80) had reviewed data prior to operation and 95% (76/80) wanted data concerning surgeons' experience, length of stay and complications including revisions. Patients expected more current monitoring of data than occurs. Of 41 surgeons, 20% (8/41) thought national joint registry (NJR) derived data accurately reflected their NHS work. Surgeons did not think this data improved patient outcomes (34%, 14/41), and that it reduced innovation (61%, 25/41) and training (75%, 31/41) and increased risk of adverse behaviour (61%, 25/41). Surgeons wanted a minimal data set accurately presented and risk adjusted.

CONCLUSION

In the future, it is likely that more individual surgeon data will be released to the public. There needs to be an agreed, accurate minimum dataset collected, reviewed in local clinical governance meetings and published with explanatory notes regarding the interfering variables and what conclusions can be drawn regarding the ability of the surgeon. This process needs to be overseen by an independent body trusted by the public.

Prospective Study of Policies and Use of Therapies for COVID-19 Amongst Australian Health Services during 2020

BACKGROUND

The COVID-19 pandemic has generated significant debate about how emerging infections can be treated in the absence of evidence-based therapies to combat disease. In particular, the use of off-label therapies outside of a clinical trial setting has been controversial.

AIM

We aimed to longitudinally study policies and prescribing practices pertaining to therapies for COVID-19 in Australian Health Services in 2020.

METHODS

Prospective data was collected from participating Australian health services who may care for patients with COVID-19 via an electronic portal. A single informant from each health service was emailed a survey link at regular intervals. Information was sought regarding changes to COVID-19 policy at their service and use of therapies for COVID-19.

RESULTS

Overall, 78 hospitals were represented from 39 respondents with longitudinal data collection from May to December 2020. All Australian states/territories were represented with the majority of respondents located in a major city (34/39; 87%). Just over half (20/39) of respondents had a written policy for COVID-19 therapy use at their health service at survey enrolment and policies changed frequently throughout the pandemic. Therapy use outside of a clinical trial was reported in 54% of health services, most frequently in Victoria, correlating with higher numbers of COVID-19 cases. At study commencement hydroxychloroquine was most frequently used, with corticosteroids and remdesivir use increasingly throughout the study period.

CONCLUSION

Our results reflect the reactive nature of prescribing of therapies for COVID-19 and highlight the importance of evidence-based guidelines to assist prescribers. This article is protected by copyright. All rights reserved.

292 Publication of Individual Surgeon Outcomes Data: The Wishes of Orthopaedic Patients and Their Surgeons

Background

The Paterson report recommended increased release of individual surgeon data to the public. There is limited evidence in the literature about patients’ or orthopaedic surgeons’ wishes regarding release of such data to the public.

Method

We surveyed 80 joint replacement patients and 41 orthopaedic surgeons to determine their wishes regarding collection and release of individual surgeon data to the public.

Results

Patients expected more current monitoring of data than actually occurs. Of the patients, 95% wanted data to be available describing surgeon experience, length of stay and complications. Regarding currently available data, 50% of patients who were aware of it were likely to view it on the internet.

Surgeons were aware of the data available, but 80% did not think it was accurate. Surgeons did not think this data improved standards, that it negatively affected innovation (61%) and training (76%) and led to risk averse behaviour (61%). Surgeons wanted a minimal data set accurately presented and risk adjusted.

Conclusions

We recommend an agreed minimum dataset of good quality data is collected and discussed in clinical governance sessions. It can then be released to the public with explanatory notes.

The effect of the COVID-19 lockdown on the epidemiology of hip fractures in the elderly: a multicentre cohort study

INTRODUCTION

The COVID-19 pandemic presented extraordinary challenges to the UK healthcare system. This study aimed to assess the impact of the COVID-19 lockdown on the epidemiology, treatment pathways and 30-day mortality rates of hip fractures. Outcomes of COVID-19 positive patients were compared against those who tested negative.

METHODS

An observational, retrospective, multicentre study was conducted across six hospitals in the South East of England. Data were retrieved from the National Hip Fracture Database and electronic medical records. Data was collected for the strictest UK lockdown period (period B=23 March 2020-11 May 2020), and the corresponding period in 2019 (period A).

RESULTS

A total of 386 patients were admitted during period A, whereas 381 were admitted during period B. Despite the suspension of the 'Best Practice Tariff' during period B, time to surgery, time to orthogeriatric assessment, and 30-day mortality were similar between period A and B. The length of inpatient stay was significantly shorter during period B (11.5 days vs 17.0 days, p<0.001). Comparison of COVID-19 positive and negative patients during period B demonstrated that a positive test was associated with a significantly higher rate of 30-day mortality (53.6% vs 6.7%), surgical delay >36h (46.4% vs 30.8%, p=0.049), and increased length of inpatient stay (15.8 vs 11.7 days, p=0.015).

CONCLUSIONS

The COVID-19 lockdown did not alter the epidemiology of hip fractures. A substantially higher mortality rate was observed among patients with a COVID-19 positive test. These findings should be taken into consideration by the healthcare policymakers while formulating contingency plans for a potential 'second wave'.

Nanoscale Pattern Extraction from Relative Positions of Sparse 3D Localizations

Inferring the organization of fluorescently labeled nanosized structures from single molecule localization microscopy (SMLM) data, typically obscured by stochastic noise and background, remains challenging. To overcome this, we developed a method to extract high-resolution ordered features from SMLM data that requires only a low fraction of targets to be localized with high precision. First, experimentally measured localizations are analyzed to produce relative position distributions (RPDs). Next, model RPDs are constructed using hypotheses of how the molecule is organized. Finally, a statistical comparison is used to select the most likely model. This approach allows pattern recognition at sub-1% detection efficiencies for target molecules, in large and heterogeneous samples and in 2D and 3D data sets. As a proof-of-concept, we infer ultrastructure of Nup107 within the nuclear pore, DNA origami structures, and α-actinin-2 within the cardiomyocyte Z-disc and assess the quality of images of centrioles to improve the averaged single-particle reconstruction.

Informed consent: the view from the trenches

We review some of the recent literature on consent for surgical procedures and suggest a scheme for obtaining surgical consent.

The incidence of anterior pituitary hormone deficiencies in patients with microprolactinoma and idiopathic hyperprolactinaemia

INTRODUCTION

Patients with microprolactinoma and idiopathic hyperprolactinaemia are not generally considered to be at risk of hypopituitarism and are therefore not routinely screened for this abnormality. In our clinical practice, we have observed a number of patients with nonmacroadenomatous hyperprolactinaemia to have anterior pituitary hormone deficits.

AIMS

We aimed to establish the frequency and clinical significance of anterior pituitary hormone deficiencies, comparing patients with radiologically proven microprolactinomas and patients with idiopathic hyperprolactinaemia.

STUDY DESIGN

We retrospectively examined the casenotes of 206 patients with hyperprolactinaemia from our centre. Patients who did not fit the profile of surgically naïve microprolactinoma or idiopathic hyperprolactinaemia or who had incomplete data were excluded, resulting in a study group of 56 patients.

RESULTS

A total of 35 patients with MRI evidence of microprolactinoma were identified, three (8.57%) of whom had one or more anterior pituitary hormone deficiencies. A total of 21 patients with MRI-negative idiopathic hyperprolactinaemia were identified, nine (42%) of whom had one or more anterior pituitary hormone deficiencies (P<.01). Only one patient in the MRI-positive group had deficiency that required hormone replacement, in contrast six patients in the MRI-negative group had deficiencies that were of clinical significance and which required hormone replacement.

SUMMARY

This study shows a clinically significant incidence of anterior pituitary hormone deficiency in patients with idiopathic hyperprolactinaemia. The authors recommend that dynamic pituitary assessment should be considered routinely in this patient group. A prospective study would be required to assess the underlying cause for these abnormalities, as they suggest a nontumour pan-pituitary process.

Hypertrophic cardiomyopathy mutations in the calponin-homology domain of ACTN2 affect actin binding and cardiomyocyte Z-disc incorporation

α-Actinin-2 (ACTN2) is the only muscle isoform of α-actinin expressed in cardiac muscle. Mutations in this protein have been implicated in mild to moderate forms of hypertrophic cardiomyopathy (HCM). We have investigated the effects of two mutations identified from HCM patients, A119T and G111V, on the secondary and tertiary structure of a purified actin binding domain (ABD) of ACTN2 by circular dichroism and X-ray crystallography, and show small but distinct changes for both mutations. We also find that both mutants have reduced F-actin binding affinity, although the differences are not significant. The full length mEos2 tagged protein expressed in adult cardiomyocytes shows that both mutations additionally affect Z-disc localization and dynamic behaviour. Overall, these two mutations have small effects on structure, function and behaviour, which may contribute to a mild phenotype for this disease.

Health level seven interoperability strategy: big data, incrementally structured

OBJECTIVES

Describe how the HL7 Clinical Document Architecture (CDA), a foundational standard in US Meaningful Use, contributes to a "big data, incrementally structured" interoperability strategy, whereby data structured incrementally gets large amounts of data flowing faster. We present cases showing how this approach is leveraged for big data analysis.

METHODS

To support the assertion that semi-structured narrative in CDA format can be a useful adjunct in an overall big data analytic approach, we present two case studies. The first assesses an organization's ability to generate clinical quality reports using coded data alone vs. coded data supplemented by CDA narrative. The second leverages CDA to construct a network model for referral management, from which additional observations can be gleaned.

RESULTS

The first case shows that coded data supplemented by CDA narrative resulted in significant variances in calculated performance scores. In the second case, we found that the constructed network model enables the identification of differences in patient characteristics among different referral work flows.

DISCUSSION

The CDA approach goes after data indirectly, by focusing first on the flow of narrative, which is then incrementally structured. A quantitative assessment of whether this approach will lead to a greater flow of data and ultimately a greater flow of structured data vs. other approaches is planned as a future exercise.

CONCLUSION

Along with growing adoption of CDA, we are now seeing the big data community explore the standard, particularly given its potential to supply analytic en- gines with volumes of data previously not possible.

'I think we're all guinea pigs really': a qualitative study of medication and borderline personality disorder

National Institute for Clinical Excellence recommended the use of medication only in times of crisis for individuals with borderline personality disorder (BPD). Despite this recommendation most service users referred to a specialist personality disorder service were found to be on numerous medications. Although a number of qualitative studies have explored the experience of individuals with a diagnosis of BPD they have failed to discuss their experience of being treated with medication, despite its high prescription with this group (e.g. Sansone et al.). The aim of this study was to explore the experience of service users being treated with medication for the BPD diagnosis. Semi-structured interviews were carried out with seven service users under a specialist service for personality disorder. Interviews were transcribed and analysed using thematic analysis. The main themes to emerge were: staff knowledge and attitudes, lack of resources for BPD and the recovery pathway for BPD. Overall, service users felt that receiving the BPD diagnosis had had a negative impact on the care they received, with staff either refusing treatment or focusing on medication as a treatment option. The introduction of specialist services for this group appears to improve service user satisfaction with their treatment and adherence to the National Institute for Clinical Excellence guidelines.

Reliability of ultrasound-measured muscle thickness of the longissimus dorsi muscle in Thoroughbreds

The purpose of this study was to determine the reliability of B-mode ultrasound measured muscle thickness of the longissimus dorsi muscle in horses. Thirteen Thoroughbreds (5 colts, 5 fillies and 3 mares) had their muscle thickness measured by B-mode ultrasound at four sites; the longissimus dorsi (LD at 30%, 50% and 70% of back length) and extensor carpi radialis (ECR) muscle on two separate test sessions (T1 and T2). Paired t-tests revealed that there was no systematic bias in any of the muscle thickness measures. There were high intraclass correlation coefficients between the LD muscle thickness at 30, 50 and 70% of back length obtained at the T1 and T2 measurements (range: 0.95-0.98). The ECR muscle thickness was positively correlated to body weight and fat-free mass while LD muscle thickness at 50% and 70% of back length did not correlate to body dimensions. Our results suggest that ultrasound measures of muscle thickness of the LD and ECR muscles are reliable and repeatable when taken with the horse standing in a relaxed and evenly balanced position.

Somnolence in adult craniopharyngioma patients is a common, heterogeneous condition that is potentially treatable

CONTEXT AND OBJECTIVE

Somnolence and obesity are prevalent in craniopharyngioma patients. We hypothesized that somnolence was because of obstructive sleep apnoea in craniopharyngioma patients.

DESIGN, PATIENTS AND MEASUREMENTS

We assessed prevalence of somnolence and sleep apnoea in 28 craniopharyngioma and 23 obese controls attending a tertiary referral centre, by means of the Epworth Sleepiness Score (ESS) and polysomnography. All subjects with sleep apnoea were offered continuous positive airway pressure therapy (CPAP) or modafinil. All craniopharyngioma patients, with unexplained somnolence, were offered modafinil.

RESULTS

Somnolence was reported by 20/28 (71·5%) craniopharyngioma patients and 4/23 (17%) obese subjects (P < 0·001). Median ESS was 7·5 (IQR 6, 10·7) in craniopharyngioma patients and 4·0 (4,8) in controls, P < 0·01. Eleven somnolent craniopharyngioma patients had obstructive sleep apnoea, in whom treatment led to a reduction in ESS by 6·4 ± 1·4, P = 0·01. Among the remaining nine patients, five were offered modafinil therapy, of whom four had benefit, three were not compliant with hormone replacement, and one died before intervention. There was no difference in the prevalence of obstructive sleep apnoea between craniopharyngioma (n = 13, 46%) and obese subjects (n = 14, 61%, P = 0·4). Body mass index (BMI) does not correlate with apnoea hypopnoea index [apnoea - hypopnoea index (AHI), r = 0·25, P = 0·08], which suggests that obesity alone does not explain the prevalence of sleep apnoea in craniopharyngioma patients.

CONCLUSIONS

Somnolence is common in craniopharyngioma patients and in the majority is because of obstructive sleep apnoea. An additional group of somnolent craniopharyngioma patients benefits from modafinil.

Fractional anisotropy of cerebral white matter and thickness of cortical gray matter across the lifespan

We examined age trajectories of fractional anisotropy (FA) of cerebral white matter (WM) and thickness of cortical gray matter (GM) in 1031 healthy human subjects (aged 11-90 years). Whole-brain FA and GM thickness values followed quadratic trajectories with age but the relationship between them was linear, indicating that a putative biological mechanism may explain the non-linearity of their age trajectories. Inclusion of the FA values into the quadratic model of the whole-brain and regional GM thickness changes with age made the effect of the age(2) term no longer significant for the whole-brain GM thickness and greatly reduced its significance for regional GM thickness measurements. The phylogenetic order of cerebral myelination helped to further explain the intersubject variability in GM thickness. FA values for the early maturing WM were significantly better (p=10(-6)) at explaining variability in GM thickness in maturing (aged 11-20) subjects than FA values for the late maturing WM. The opposite trend was observed for aging subjects (aged 40-90) where FA values for the late maturing WM were better (p=10(-16)) at explaining the variability in GM thickness. We concluded that the non-linearity of the age trajectory for GM thickness, measured from T1-weighted MRI, was partially explained by the heterogeneity and the heterochronicity of the age-related changes in the microintegrity of cerebral WM. We consider these findings as the evidence that the measurements of age-related changes in GM thickness and FA are driven, in part, by a common biological mechanism, presumed to be related to changes in cerebral myelination.

Integration of Multi-Level Copper Metallization into a High Performance Sub-0.25μM Technology

We report the integration of six levels of Cu interconnects using dual inlaid patterning in a 0.2 μm logic technology. A review of process technology as well as device performance shortcomings using conventional aluminum metallization has been presented. Two tantalum based barriers, TaNx and Ta-Si-N as well as a titanium based barrier, CVD TiN, have been evaluated for their applicability. The use of embedded barriers wherein the barrier is formed below the surface of the dielectric has also been discussed as a potential option. No degradation to the device front-end parametrics were found with the choice of an appropriate barrier. Planarization by Cu CMP introduces surface topography that needs to be minimized in order to process multiple levels of interconnects within specified sheet resistance distributions for a range of line widths. Excellent results with highly planarized levels of metallization have consistently been achieved through an optimization of the unit processes and device integration.