SLAMF7 engagement superactivates macrophages in acute and chronic inflammation

Macrophages regulate protective immune responses to infectious microbes, but aberrant macrophage activation frequently drives pathological inflammation. To identify regulators of vigorous macrophage activation, we analyzed RNA-seq data from synovial macrophages and identified SLAMF7 as a receptor associated with a superactivated macrophage state in rheumatoid arthritis. We implicated IFN-γ as a key regulator of SLAMF7 expression and engaging SLAMF7 drove a strong wave of inflammatory cytokine expression. Induction of TNF-α after SLAMF7 engagement amplified inflammation through an autocrine signaling loop. We observed SLAMF7-induced gene programs not only in macrophages from rheumatoid arthritis patients but also in gut macrophages from patients with active Crohn's disease and in lung macrophages from patients with severe COVID-19. This suggests a central role for SLAMF7 in macrophage superactivation with broad implications in human disease pathology.

Does the Preferred Study Source Impact Orthopedic In-Training Examination Performance?

OBJECTIVE

This study examines the role of electronic learning platforms for medical knowledge acquisition in orthopedic surgery residency training. This study hypothesizes that all methods of medical knowledge acquisition will achieve similar levels of improvement in medical knowledge as measured by change in orthopedic in-training examination (OITE) percentile scores. Our secondary hypothesis is that residents will equally value all study resources for usefulness in acquisition of medical knowledge, preparation for the OITE, and preparation for surgical practice.

DESIGN

9 ACGME accredited orthopedic surgery programs participated with 95% survey completion rate. Survey ranked sources of medical knowledge acquisition and study habits for OITE preparation. Survey results were compared to OITE percentile rank scores.

PARTICIPANTS

386 orthopedic surgery residents SETTING: 9 ACGME accredited orthopaedic surgery residency programs RESULTS: 82% of participants were utilizing online learning resources (Orthobullets, ResStudy, or JBJS Clinical Classroom) as primary sources of learning. All primary resources showed a primary positive change in OITE score from 2018 to 2019. No specific primary source improved performance more than any other sources. JBJS clinical classroom rated highest for improved medical knowledge and becoming a better surgeon while journal reading was rated highest for OITE preparation. Orthopedic surgery residents' expectation for OITE performance on the 2019 examination was a statistically significant predictor of their change (decrease, stay the same, improve) in OITE percentile scores (p<0.001).

CONCLUSIONS

Our results showed that no specific preferred study source outperformed other sources. Significantly 82% of residents listed an online learning platform as their primary source which is a significant shift over the last decade. Further investigation into effectiveness of methodologies for electronic learning platforms in medical knowledge acquisition and in improving surgical competency is warranted.

What Is the Prevalence of Burnout, Depression, and Substance Use Among Orthopaedic Surgery Residents and What Are the Risk Factors? A Collaborative Orthopaedic Educational Research Group Survey Study

BACKGROUND

Burnout and depression among healthcare professionals and trainees remain alarmingly common. In 2009, 56% of orthopaedic surgery residents reported burnout. Alcohol and illicit drug use are potential exacerbating factors of burnout and depression; however, these have been scarcely studied in residency populations.

QUESTIONS/PURPOSES

(1) What proportion of orthopaedic residents report symptoms of burnout and depression? (2) What factors are independently associated with an orthopaedic resident reporting emotional exhaustion, depersonalization, low personal accomplishment, and depression? (3) What proportion of orthopaedic residents report hazardous alcohol or drug use? (4) What factors are independently associated with an orthopaedic resident reporting hazardous alcohol or drug use?

METHODS

We asked 164 orthopaedic surgery programs to have their residents participate in a 34-question internet-based, anonymous survey, 28% of which (46 of 164) agreed. The survey was distributed to all 1147 residents from these programs, and 58% (661 of 1147) of these completed the survey. The respondents were evenly distributed among training years. Eighty-three percent (551 of 661) were men, 15% (101 of 661) were women, and 1% (nine of 661) preferred not to provide their gender. The survey asked about demographics, educational debt, sleep and work habits, perceived peer or program support, and substance use, and validated instruments were used to assess burnout (abbreviated Maslach Burnout Inventory), depression (Patient Health Questionnaire-2), and hazardous alcohol use (Alcohol Use Disorder Identification Test-Consumption). The main outcome measures included overall burnout, emotional exhaustion, depersonalization, low personal accomplishment, depression, and hazardous alcohol and drug use. Using the variables gathered in the survey, we performed an exploratory analysis to identify significant associations for each of the outcomes, followed by a multivariable analysis.

RESULTS

Burnout was reported by 52% (342 of 661) of residents. Thirteen percent of residents (83 of 656) had positive screening results for depression. Factors independently associated with high emotional exhaustion scores included early training year (odds ratio 1.15; 95% confidence interval, 1.01-1.32; p = 0.03) unmanageable work volume (OR 3.13; 95% CI, 1.45-6.67; p < 0.01), inability to attend health maintenance appointments (OR 3.23; 95% CI, 1.69-6.25; p < 0.01), lack of exercise (OR 1.69; 95% CI, 1.08-2.70; p = 0.02), and lack of program support (OR 3.33; 95% CI, 2.00-5.56; p < 0.01). Factors independently associated with depersonalization included early training year (OR 1.27; 95% CI, 1.12-1.41; p < 0.01), inability to attend health maintenance appointments (OR 2.70; 95% CI, 1.67-4.35; p < 0.01), and lack of co-resident support (OR 2.52; 95% CI, 1.52-4.18; p < 0.01). Low personal accomplishment was associated with a lack of co-resident support (OR 2.85; 95% CI, 1.54-5.28; p < 0.01) and lack of program support (OR 2.33; 95% CI, 1.32-4.00; p < 0.01). Factors associated with depression included exceeding duty hour restrictions (OR 2.50; 95% CI, 1.43-4.35; p < 0.01) and lack of program support (OR 3.85; 95% CI, 2.08-7.14; p < 0.01). Sixty-one percent of residents (403 of 656) met the criteria for hazardous alcohol use. Seven percent of residents (48 of 656) reported using recreational drugs in the previous year. Factors independently associated with hazardous alcohol use included being a man (OR 100; 95% CI, 35-289; p < 0.01), being Asian (OR 0.31; 95% CI, 0.17-0.56; p < 0.01), single or divorced marital status (OR 2.33; 95% CI, 1.47-3.68; p < 0.01), and more sleep per night (OR 1.92; 95% CI, 1.21-3.06; p < 0.01). Finally, single or divorced marital status was associated with drug use in the past year (OR 2.30; 95% CI, 1.26-4.18; p < 0.01).

CONCLUSIONS

The lack of wellness among orthopaedic surgery residents is troubling, especially because most of the associated risk factors are potentially modifiable. Programs should capitalize on the modifiable elements to combat burnout and improve overall wellbeing. Programs should also educate residents on burnout, focus on work volume, protect access to health maintenance, nurture those in the early years of training, and remain acutely aware of the risk of substance abuse. Orthopaedic surgery trainees should strive to encourage peer support, cultivate personal responsibility, and advocate for themselves or peers when faced with challenges. At a minimum, programs and educational leaders should foster an environment in which admitting symptoms of burnout is not seen as a weakness or failure.

LEVEL OF EVIDENCE

Level II, prognostic study.

Radiographic Predictors of Medial Collateral Ligament Injury and Stability of the Elbow

It has been postulated that injury to the medial collateral ligament (MCL) of the elbow is rare in cases of elbow fracture-dislocation, and if the MCL is torn, it does not require surgical repair. Elbow fracture-dislocations with MCL insufficiency are associated with recurrent instability, secondary surgery, and the development of posttraumatic arthritis. With the current study, our aim was to investigate whether evidence of an MCL attachment-site fracture on a radiograph or computed tomography (CT) scan is predictive of MCL insufficiency, the need for MCL repair, and postoperative instability.

What Predicts Outstanding Orthopedic Residents among the Program?

BACKGROUND

An oversupply of qualified applicants leads to intense competition for the limited number of first year orthopedic residency positions. Therefore, program directors can be more selective in choosing their future residents. However, it is unclear if there are resident characteristics that correspond with trainee performance.

METHODS

We asked (1) what resident characteristics are associated with subjective residency performance score? and (2) what resident characteristics are associated with Orthopedic In-Training Examination (OITE) score?A total of 119 orthopedic residents accepted at the Harvard Combined Orthopedic Residency Program from 1999 - 2009 were included in this study. The current program director together with two former program directors in the selected time period defined the subjective residency performance score based on the clinical skills of the residents during training.

RESULTS

Former Olympic or varsity athlete (P=0.018) and Alpha Omega Alpha (AOA) status (P=0.014) were associated with a better subjective residency performance score. Higher USMLE step 1 score (P=0.0038), known person within faculty prior to the residency (did a research rotation, or local medical student) (P=0.041), and AOA (P=0.015) status were associated with a higher OITE score.

CONCLUSION

AOA status of the applicant for orthopedic residency is associated with both a higher OITE score and a better subjective residency performance score.

A Self-Reported Needs Assessment Survey of Pediatric Orthopaedic Education in Haiti

OBJECTIVE

The burden of musculoskeletal disease remains high in low-income countries, with a high rate of pediatric disease. Efforts continue for orthopedic education, but there is little guidance on local needs and desires. Our aim was to determine the specific content and modalities that would be most useful for pediatric orthopedic educational programs abroad, and we demonstrate a practical method of identifying country-specific educational deficits through a self-reported needs survey in Haiti.

DESIGN

A cross-sectional survey was administered using an automated response system. We obtained demographic information as well as training and practice patterns, comfort levels with pediatric diagnoses, and desired topics for education using a 5-point Likert Scale.

SETTING

Haitian Annual Assembly for Orthopaedic Trauma (HAAOT), the only national, continuing medical education conference for orthopedic providers in Haiti.

PARTICIPANTS

Of 60 eligible participants, 51 were included in the final analysis.

RESULTS

Time spent on pediatric orthopedics varied widely, centered at 10% to 25%. Median comfort level with pediatric orthopedics was 3 of 5. Skills with lowest self-reported competence included spica casting, clubfoot casting, and management of supracondylar humerus fractures. Skills with highest self-reported competence were long-leg casting and Salter-Harris classification. Modes of education highly requested included didactics/lectures, hands-on sessions, dedicated rotations, and exchanges with foreign peers/mentors. Diagnoses most encountered were osteomyelitis, trauma, and clubfoot; lowest comfort levels were in neuromuscular, spine, lower extremity deformity, congenital hip, and clubfoot; and most requested for future teaching were congenital hip, neuromuscular, and spine.

CONCLUSIONS

Haitian orthopedic providers express a strong desire and need for ongoing pediatric orthopedic education. They describe a high prevalence of trauma and infection, but convey a requirement for more comprehensive, multimodal teaching that also includes congenital deformities/dysplasias, neuromuscular, and spine. Our results demonstrate the importance of assessing country-specific needs and involving local care providers in curriculum development.

What Factors are Associated With a Surgical Site Infection After Operative Treatment of an Elbow Fracture?

BACKGROUND

Surgical site infections are one of the more common major complications of elbow fracture surgery and can contribute to other adverse outcomes, prolonged hospital stays, and increased healthcare costs.

QUESTIONS/PURPOSES

We asked: (1) What are the factors associated with a surgical site infection after elbow fracture surgery? (2) When taking the subset of closed elbow fractures only, what are the factors associated with a surgical site infection? (3) What are the common organisms isolated from an elbow infection after open treatment?

METHODS

One thousand three hundred twenty adult patients underwent surgery for an elbow fracture between January 2002 and July 2014 and were included in our study. Forty-eight of 1320 patients (4%) had a surgical site infection develop. Thirty-four of 1113 patients with a closed fracture (3%) had a surgical site infection develop.

RESULTS

For all elbow fractures, use of plate and screw fixation (adjusted odds ratio [OR]= 2.2; 95% CI, 1.0-4.5; p = 0.041) and use of external fixation before surgery (adjusted OR = 4.7; 95% CI, 1.1-21; p = 0.035) were associated with higher infection rates. When subset analysis was performed for closed fractures, only smoking (adjusted OR = 2.2; 95% CI, 1.1-4.5; p = 0.023) was associated with higher infection rates. Staphylococcus aureus was the most common bacteria cultured (59%).

CONCLUSIONS

The only modifiable risk factor for a surgical site infection after open reduction and internal fixation was cigarette smoking. Plate fixation and temporary external fixation are likely surrogates for more complex injuries, therefore no recommendations should be inferred from this association. Surgeons should counsel patients who smoke.

LEVEL OF EVIDENCE

Level IV, prognostic study.

Risk factors for fracture mobility six weeks after initiation of brace treatment of mid-diaphyseal humeral fractures

BACKGROUND

Recent studies have identified specific subsets of diaphyseal humeral fractures for which functional bracing is less effective. The present study tested the hypothesis that a gap between fracture fragments may be a risk factor (after accounting for other potential risk factors) for fracture instability six weeks after functional bracing of humeral shaft fractures.

METHODS

We retrospectively identified seventy-nine adult patients (forty-six men, thirty-three women; forty-two fractures on the right side, thirty-seven fractures on the left), each with an acute, closed, AO type-A2 (oblique, ≥30°) or type-A3 (transverse, <30°) mid-diaphyseal humeral shaft fracture treated nonoperatively at three different level-I trauma centers from June 2004 to August 2011. The gap between the fracture fragments was measured on the first radiographs made after the affected upper extremity was placed in a brace.

RESULTS

Sixty-three patients (80%) had documented healing of the fracture. Sixteen patients (20%) had motion at the fracture site and a persistent fracture line shown on radiographs six weeks or more after injury. In multivariable analysis, each millimeter of gap between the main fragments with the patient wearing the brace (odds ratio [OR] = 1.4, 95% confidence interval [CI] = 1.1 to 1.7), smoking (OR = 5.8, 95% CI = 1.4 to 25), and female sex (OR = 5.3, 95% CI = 1.2 to 23) increased the risk of fracture instability six weeks after injury (R2 = 0.38, area under the receiver operating characteristic [ROC] curve = 0.81).

CONCLUSIONS

The magnitude of the gap between the fracture fragments is an independent risk factor for fracture instability and the lack of a bridging callus six weeks after a diaphyseal humeral fracture.

Diagnostic accuracy of 2- and 3-dimensional imaging and modeling of distal humerus fractures

PURPOSE

This investigation used prospectively recorded intraoperative evaluation as the reference standard for distal humerus fracture type and characteristics, in order to measure the diagnostic performance characteristics of computed tomography (CT) and physical models. In secondary analyses, we assessed the reliability of classification.

METHODS

Thirty-five fractures were evaluated by the treating surgeon and first assistant on radiographs and 2-dimensional CT (2DCT) images first; a second time based on radiographs and 2- and 3-dimensional CT (3DCT) images; a third time based on 2- and 3DCT as well as 3D physical models; and a fourth time based on intraoperative visualization of the fracture characteristics. The intraoperative evaluation of the attending surgeon was used as the reference standard.

RESULTS

The addition of 3DCT and the 3D models to 2DCT and radiographs led to significant improvements in sensitivity, but not specificity, in the diagnosis and proposed treatment, and improved the interobserver agreement with respect to specific fracture characteristics but not classification.

CONCLUSION

Increasingly sophisticated imaging and modeling leads to slight but significant improvements in diagnostic performance characteristics and interobserver agreement on fracture characteristics.

Quidne mortui vivos docent? The evolving purpose of human dissection in medical education

The dissection experience has evolved over the past 500 years, following broader cutural trends in science and medicine. Through this time each period has recruited human gross anatomic dissection for characteristic purposes. Key variables have been: (1) the motivating philosophies of medicine and science, (2) how well clinical medicine and basic science have been integrated by anatomy, and (3) how explicity thoughts or feelings about death and dying have been addressed in the context of anatomy. The authors are especially interested in the third variable, and suggest that although anatomy is scientifically in decline, dissection is currently enjoying a revival as a vehicle for teaching humanist values in medical school. Changes in the culture of medicine have carried anatomy from a research science, to a training tool, nearly to a hazing ritual, to a vehicle for ethical and moral education. Physicians, scientists, and medical students, as well as observers such as sociologists and writers, have been only intermittently aware of these cultural shifts. Yet anatomic dissection has been remarkably persistent as a feature of medical education-indeed it stands out as the most universal and universally recognizable step in becoming a doctor. This paper attempts to explore and interpret in detail the history of anatomy education, drawing on both subjective commentary and objective data from each period.

Age effects on orthodontic treatment: adolescents contrasted with adults

Skeletodental treatment changes in 30 adolescent girls and 26 women who had Class II, Division 1 malocclusions were contrasted cephalometrically, primarily with the McNamara analysis. The data show that adult treatment does not obligate the practitioner to longer treatment. In this study, both age groups were treated in 2.5 years on the average. Apical base corrections were achieved with equal facility in both groups by the posterior remodeling of point A, and this (in conjunction with unrestrained mandibular growth) is the major source of correction in the adolescents. In adults, in whom growth is trivial, an appreciable source of sagittal correction is the steepening of the occlusal plane. Several sequelae of Class II elastic force occurred as by-products of molar correction in the adults: increased mandibular molar eruption, increased maxillary molar intrusion, increased maxillary incisor eruption, increased mandibular incisor intrusion, and steepening of the occlusal plane.

Age effects on orthodontic treatment: skeletodental assessments from the Johnston analysis

We have compared differences in treatment outcomes dependent on patient age, either adolescent (means = 12.5 years at start) or adult (means = 27.6). Subjects were female patients whose Class II, Division 1 malocclusions were treated with Tweed edgewise mechanics and four-premolar extractions. Cephalometric records were assessed according to the Johnston analysis. The functional occlusal plane remained stable during mechanotherapy in the adolescents, whereas it steepened considerably in the adults. Differential mandibular growth in adolescents contributed 70% of the total molar correction, with orthodontic tooth movement accounting for the other 30%. Maxillary growth in the adults detracted from the Class II molar correction; tooth movement accounted for virtually all of the correction.