Comparison of medical students' considerations in choosing a specialty: 2020 vs. 2009/10

BACKGROUND

Workforce shortage in healthcare and particularly in physicians poses a threat to healthcare delivery and its quality. In comparison to other OECD countries, Israel currently has a small number of medical graduates relative to its number of physicians, naturally emphasizing the importance of ensuring that this population chooses to remain in medicine. Understanding what is most important to medical students can help improve working conditions in residency. Such information is particularly needed to facilitate policy planning that will encourage the next generation of physicians to specialize in medical fields that are experiencing shortages. We hypothesized that between 2009/2010 and 2020, there were significant changes in medical students' preferences regarding their considerations for choosing a medical specialty.

METHODS

We compared cross-sectional data from questionnaire-based surveys of 5th year medical students performed in 2009-2010 and 2020 at two Israeli universities.

RESULTS

Of the 335 medical students who responded (237 and 98 in 2009/2010 and 2020, respectively) those in 2020 were 2.26 less likely vs. those in 2009/2010, to choose a residency for its high-paying potential (P < 0.05), and had significantly more interest in residencies with greater teaching opportunity (98.8% vs 82.9%, P < 0.05), increased responsibility and chances to make clinical decisions on their own (67.9% vs 51.6%, P < 0.05). Criteria important to both the 2009/2010 and 2020 students were choosing a bedside specialty (70.2%vs 67.9%, NS), and an interesting and challenging specialty (95.2%v s 91.3%, NS).

CONCLUSIONS

These results partially supported our hypothesis that medical students' preferences have changed over the years, though there are fundamental factors that apparently reflect medical students' nature that do not change over time.

Long-Term Effects on Sexual Function in Women Treated With Scoliosis Correction for Adolescent Idiopathic Scoliosis

STUDY DESIGN

Retrospective cohort study with a cross-sectional comparison.

OBJECTIVES

To assess sexual function and experience in adult women who had scoliotic correction for adolescent idiopathic scoliosis (AIS).

METHODS

Women ages 18-40 years with a history of scoliosis, who were braced or underwent uncomplicated posterior scoliosis correction for AIS, followed for two years or more since treatment were included. Sexual function was assessed using the Female Sexual Distress Scale-Revised (FSDS-R) and the Female Sexual Function Index (FSFI) questionnaires. Participants' scores were compared to those of a control group consisting of age-matched healthy women.

RESULTS

Of 115 women who responded to the questionnaires, 40 (35%) had surgical treatment (mean age 25.1; range 19-35 years; mean time since surgery 8.2 years; range 3-12 years) and 35 (30%) were braced (mean age 23.3; range 18-27 years; mean time since treatment 3.6 years; range 3-5 years). The control group consisted of a cohort of 40 (35%) aged-matched healthy women. According to the FSDS-R, significantly more women with scoliotic correction for AIS reported sexual distress compared to healthy controls (25% vs 12%, respectively), and the difference in the total mean scores (7.05 vs 5.34, respectively), was significant (P < .001). Additionally, the mean overall FSFI score for scoliotic-corrected women was 24.2 (range 17.5-29.1) within the pathological range (<26.55) of sexual dysfunction.

CONCLUSIONS

High rates of sexual distress and dysfunction were reported in women with a history of AIS, thus, there appears to be long-term consequences years after deformity correction by brace or surgical correction.

Intraoperative Deterioration of Neurophysiological Potentials of the Spinal Tracts in Cervical Spine Surgery: Correlation With Patient-Related and Procedure-Related Variables

PURPOSE

To identify characteristics associated with higher incidence of intraoperative deterioration of neurophysiological potentials related to spinal tracts in cervical spine surgeries.

METHODS

Electrophysiological raw data and neurophysiological case reports of 1,611 patients from multiple medical centers, who underwent cervical spine surgery for decompression and/or fusion, were retrospectively reviewed. Patient-related and procedure-related variables were identified and analyzed for correlation with intraoperative neurophysiological event of the spinal tracts. The neurophysiological events were analyzed for identification of collective characteristics.

RESULTS

The study cohort presented consistent dominancy of male over female patients (67% vs. 33%). Intraoperative deterioration of spinal tract-derived potentials was noted in 10.5% of the total cases, which was not correlated with gender, age, or indication of the surgery. Higher incidence of neurophysiological events was noted in patients with impaired baseline of motor evoked potentials from the thenar muscle ( P = 0.01) or somatosensory evoked potentials of the posterior tibial nerve ( P = 0.0002). Procedures of circumferential approach or procedures that involved ≥3 spinal levels demonstrated higher incidence of neurophysiological events as well ( P = 0.0003 and 0.001, respectively).

CONCLUSIONS

Patients with deteriorated neurophysiological baseline and procedures of extensive intervention are at higher risk of intraoperative neurophysiological event in cervical spine surgery. Inclusion of intraoperative neurophysiological monitoring should be encouraged in complicated cases of cervical spine surgeries.

When giants talk; robotic dialog during thoracolumbar and sacral surgery

Background

Spinal trauma patients treated in a specialized hybrid operating room (OR) using two robotic systems communicating during surgery.

Methods

Retrospective review of patients with thoracolumbar or sacral fractures who underwent surgical fixation between Jan 2017 to Jan 2020 with robotic-guided percutaneous pedicle screw insertion in the specialized hybrid OR with Robotic flat panel 3D C-arm (ArtisZeego) for intraoperative interventional imaging connected with the robotic-guidance platform Renaissance (Mazor Robotics).

Results

Twenty eight surgeries were performed in 27 patients; 23 with traumatic spinal fractures, 4 with multi-level thoracolumbar compression fractures due to severe osteoporosis. Average patient age 49 (range 12–86). Average radiation exposure time 40 s (range 12–114 s). Average radiation exposure dose 11,584 ± SD uGym² (range 4454–58,959). Lumber levels operated on were between T5 and S2 (shortest three vertebras and longest eight vertebras). 235 (range 5–11) trajectories were performed. All trajectories were accurate in all cases percutaneous pedicle screws placement was correct, without breach noted at the pedicle in any of the cases. No major complications reported. In all cases, follow-up X-rays showed adequate fracture reduction with restoration.

Conclusions

Merging of surgical robotics technologies increases patient safety and surgeon and patient confidence in percutaneous spine traumatic procedures.

Tailoring the lipid composition of nanoparticles modulates their cellular uptake and affects the viability of triple negative breast cancer cells

Lipid nanoparticles are used widely as anticancer drug and gene delivery systems. Internalizing into the target cell is a prerequisite for the proper activity of many nanoparticulate drugs. We show here, that the lipid composition of a nanoparticle affects its ability to internalize into triple-negative breast cancer cells. The lipid headgroup had the greatest effect on enhancing cellular uptake compared to other segments of the molecule. Having a receptor-targeted headgroup induced the greatest increase in cellular uptake, followed by cationic amine headgroups, both being superior to neutral (zwitterion) phosphatidylcholine or to negatively-charged headgroups. The lipid tails also affected the magnitude of cellular uptake. Longer acyl chains facilitated greater liposomal cellular uptake compared to shorter tails, 18:0 > 16:0 > 14:0. When having the same lipid tail length, unsaturated lipids were superior to saturated ones, 18:1 > 18:0. Interestingly, liposomes composed of phospholipids having 14:0 or 12:0-carbon-long-tails, such as DMPC and DLPC, decreased cell viability in a concertation dependent manner, due to a destabilizing effect these lipids had on the cancer cell membrane. Contrarily, liposomes composed of phospholipids having longer carbon tails (16:0 and 18:0), such as DPPC and HSPC, enhanced cancer cell proliferation. This effect is attributed to the integration of the exogenous liposomal lipids into the cancer-cell membrane, supporting the proliferation process. Cholesterol is a common lipid additive in nanoscale formulations, rigidifying the membrane and stabilizing its structure. Liposomes composed of DMPC (14:0) showed increased cellular uptake when enriched with cholesterol, both by endocytosis and by fusion. Contrarily, the effect of cholesterol on HSPC (18:0) liposomal uptake was minimal. Furthermore, the concentration of nanoparticles in solution affected their cellular uptake. The higher the concentration of nanoparticles the greater the absolute number of nanoparticles taken up per cell. However, the efficiency of nanoparticle uptake, i.e. the percent of nanoparticles taken up by cells, decreased as the concentration of nanoparticles increased. This study demonstrates that tuning the lipid composition and concentration of nanoscale drug delivery systems can be leveraged to modulate their cellular uptake.

Ambulation and survival following surgery in elderly patients with metastatic epidural spinal cord compression

BACKGROUND AND CONTEXT

Metastatic epidural spinal cord compression (MESCC) is a disabling consequence of disease progression. Surgery can restore or preserve physical function, improving access to treatments that increase duration of survival; however, advanced patient age may deter oncologists and surgeons from considering surgical management.

PURPOSE

Evaluate the duration of ambulation and survival in elderly patients following surgical decompression of MESCC.

STUDY DESIGN/SETTING

Retrospective file review of a prospective database, under institutional review board (IRB) waiver of informed consent, of consecutive patients treated in an academic tertiary care medical center from August 2008 to March 2015.

PATIENT SAMPLE

Patients ≥65 years presenting neurological and/or radiological signs of cord compression because of metastatic disease, who underwent surgical decompression.

OUTCOME MEASURES

Duration of ambulation and survival.

METHODS

Patients underwent urgent multidisciplinary evaluation and surgery. Ambulation and survival were compared with age, pre-, and postoperative neurological (American Spinal Injury Association [ASIA] Impairment Scale [AIS]) and performance status (Karnofsky Performance Status [KPS]), and Tokuhashi Score using Kruskal-Wallis and Wilcoxon signed rank tests, Pearson correlation coefficient, Cox regression model, log-rank analysis, and Kaplan-Meier analysis.

RESULTS

Forty patients were included (21 male, 54%; mean age 74 years, range 65-87). Surgery was performed a mean 3.8 days after onset of motor symptoms. Mean duration of ambulation and survival were 474 (range 0-1662) and 525 days (range 11-1662), respectively; 53% of patients (21 of 40) survived and 43% (17 of 40) retained ambulation for ≥1 year. There was no significant relationship between survival and ambulation for patients aged 65-69, 70-79, or 80-89 years, although Kaplan-Meier analysis suggested stratification. There was a significant relationship between duration of ambulation and pre- and postoperative AIS (p=.0342, p=.0358, respectively) and postoperative KPS (p=.0221). Tokuhashi score was not significantly related to duration of survival or ambulation, and greatly underestimated life expectancy in 22 of 37 (59%) patients with scores 0-11.

CONCLUSIONS

Decompressive surgery led to marked improvement in neurological function and performance status. More than 50% of patients survived for >1 year, some for 3 years or more after surgery.

Blood Transfusion and Postoperative Infection in Spine Surgery: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

Allogeneic blood transfusion-related immunomodulation may relatively suppress the immune system, heightening the risk of infection following spine surgery. This systematic review seeks to determine whether allogeneic blood transfusion increases the risk of postoperative infection and whether there are any factors that modify this association.

METHODS

PubMed, Cochrane Central Register of Controlled Trials, and reference lists from included studies were searched from inception to April 20, 2017 to identify studies examining the risk of infection following allogeneic blood transfusion in adult patients receiving surgery for degenerative spine disease.

RESULTS

Eleven retrospective cohort or case-control studies, involving 8428 transfusion patients and 43 242 nontransfusion patients, were identified as meeting the inclusion criteria. Regarding surgical site infection (SSI), the results were mixed with roughly half reporting a significant association. There was an association between allogeneic transfusion and urinary tract infection (UTI) and any infection, but not respiratory tract infection. There was no statistical modifying effect of lumbar versus thoracic surgery on the association of allogeneic transfusion and SSI, though subgroup analyses in 3 of 4 studies reported a statistical association between transfusion and postoperative infections, including SSI, UTI, and any infection within the lumbar spine.

CONCLUSIONS

This systematic review failed to find a consistent association between allogeneic transfusion and postoperative infection in spine surgery patients. However, these studies were all retrospective with a high or moderately high risk of bias. To properly examine this association an observational prospective study of sufficient power, estimated as 2400 patients, is required.

Nanoparticles target early-stage breast cancer metastasis in vivo

Despite advances in cancer therapy, treating cancer after it has metastasized remains an unmet clinical challenge. In this study we demonstrate that 100 nm liposomes target triple-negative murine breast-cancer metastases post intravenous administration. Metastatic breast cancer was induced in BALB/c mice either experimentally, by a tail vein injection of 4T1 cells, or spontaneously, after implanting a primary tumor xenograft. To track their biodistribution in vivo the liposomes were labeled with multi-modal diagnostic agents, including indocyanine green and rhodamine for whole-animal fluorescent imaging, gadolinium for magnetic resonance imaging (MRI), and europium for a quantitative biodistribution analysis. The accumulation of liposomes in the metastases peaked at 24 h post the intravenous administration, similar to the time they peaked in the primary tumor. The efficiency of liposomal targeting to the metastatic tissue exceeded that of a non-liposomal agent by 4.5-fold. Liposomes were detected at very early stages in the metastatic progression, including metastatic lesions smaller than 2 mm in diameter. Surprisingly, while nanoparticles target breast cancer metastasis, they may also be found in elevated levels in the pre-metastatic niche, several days before metastases are visualized by MRI or histologically in the tissue. This study highlights the promise of diagnostic and therapeutic nanoparticles for treating metastatic cancer, possibly even for preventing the onset of the metastatic dissemination by targeting the pre-metastatic niche.

Using medical specialty and selection criteria clusters to study specialty selection by Israeli medical students

BACKGROUND

During their final year of medical school, Israeli students must consider which specialty to choose for residency. Based on the vocational counseling literature we presumed that choices are made by selecting from a cluster of related specialties while considering professional and socio-economic issues.

METHODS

Questionnaires distributed to final-year medical students at two Israeli medical schools ascertained inclinations toward various medical specialties and the importance of various selection criteria. Analysis focused on seven specialties where >20% of students reported they had positive inclinations. For each such specialty, the specialty and selection criteria query were compared using unpaired two-tailed Student's t-tests to determine differences between students with positive inclinations toward the specialty with those not so inclined. These data were placed in tables, with the significant differences highlighted to facilitate visual recognition of cluster patterns.

RESULTS

Completed questionnaires were obtained from 317 of 455 students. Students often had positive inclinations toward more than one specialty (specialty clusters) associated with a group of selection criteria (selection criteria clusters). For example, interest in internal medicine was clustered with interest in internal medicine subspecialties, cardiology and research. Furthermore, there was a "reciprocal" aspect to some specialty cluster patterns. For example, those interested in internal medicine had little interest in surgical specialties. Selection criteria clusters revealed occupational interests and socio-environmental factors associated with the specialty clusters. For example, family medicine, which clustered with pediatrics and psychiatry, had a sub-cluster of: Bedside specialty with family orientation affording long-term patient care. Another sub-cluster was time for childrearing and family, only daytime work and outpatient care. Clusters also revealed students' perceptions that differed from expected: Cardiology is changing from a cognitive to a procedure-oriented subspecialty, clustering not only with internal medicine and its subspecialties but also with emergency medicine, surgical subspecialties and anesthesiology.

CONCLUSIONS

The concept that career choice involves selecting from a cluster of related specialties provides information about the specialties students might be considering. Moreover, students are not only looking for individual aspects of a specialty, but for a package including clusters of socio-economic and occupational features. Practically, examining clusters can help in career counseling of medical students and assist residency program directors in marketing their specialties.

Erratum: Adolescent Idiopathic Scoliosis and Pregnancy: An Unsolved Paradigm

[This corrects the article DOI: 10.1055/s-0035-1552987.].

Value of repeat CT scans in low back pain and radiculopathy

We assessed the clinical value of repeat spine CT scan in 108 patients aged 18-60 years who underwent repeat lumbar spine CT scan for low back pain or radiculopathy from January 2008 to December 2010. Patients with a neoplasm or symptoms suggesting underlying disease were excluded from the study. Clinical data was retrospectively reviewed. Index examinations and repeat CT scan performed at a mean of 24.3 ± 11.3 months later were compared by a senior musculoskeletal radiologist. Disc abnormalities (herniation, sequestration, bulge), spinal stenosis, disc space narrowing, and bony changes (osteophytes, fractures, other changes) were documented. Indications for CT scan were low back pain (60 patients, 55%), radiculopathy (46 patients, 43%), or nonspecific back pain (two patients, 2%). A total of 292 spine pathologies were identified in 98 patients (90.7%); in 10 patients (9.3%) no spine pathology was seen on index or repeat CT scan. At repeat CT scan, 269/292 pathologies were unchanged (92.1%); 10/292 improved (3.4%), 8/292 worsened (2.8%, disc herniation or spinal stenosis), and five new pathologies were identified. No substantial therapeutic change was required in patients with worsened or new pathology. Added diagnostic value from repeat CT scan performed within 2-3 years was rare in patients suffering chronic or recurrent low back pain or radiculopathy, suggesting that repeat CT scan should be considered only in patients with progressive neurologic deficits, new neurologic complaints, or signs implying serious underlying conditions.

The use of local vancomycin powder in degenerative spine surgery

PURPOSE

Wound infection after spine surgery is a debilitating complication. Local placement of vancomycin powder into the surgical wounds prior to closing of the fascia has been introduced as a method to reduce deep infection rates.

METHODS

The infection rates of all the patients who were treated with intra-operative local vancomycin between June 2012 and June 2013 were compared to all cases that were not treated with vancomycin between January 2009 and December 2010. Patients for both groups were operated by four senior, fellowship-trained spine surgeons with a combined experience of 55 years of practice at a referral orthopedic center. Patients' charts and microbiology reports were reviewed.

RESULTS

1224 cases were performed with the use of vancomycin. The average age was 56.3 years (SD -13.2; NS). The male to female ratio was 1:1.12 (NS). 2253 cases were performed without the use of vancomycin. The average patient age was 57.1 years (SD 14.5). The male to female ratio was 1:1.14. There were 30 cases of deep infections needing a surgical irrigation and debridement without vancomycin versus 5 when vancomycin was used (P = 0.04). Infections in patients treated with vancomycin were not vancomycin-resistant bacteria.

CONCLUSION

In conclusion, the use of vancomycin reduces the rate of deep wound infections and irrigation and debridement procedures after spine surgery in a referral center among surgeons with a high surgical volume.

Adolescent Idiopathic Scoliosis and Pregnancy: An Unsolved Paradigm

Study Design Retrospective cohort study with a cross-sectional comparison. Objective To compare the rates of anesthesia prescription and satisfaction with surgery, prevalence and severity of low back pain, prevalence of depression, and sexual dysfunction among pregnant and nonpregnant patients with AIS undergoing correction surgery with pedicle-based systems and healthy woman with a history of pregnancy. Methods Women between the ages of 18 and 40 years who underwent correction surgery for AIS with a pedicle screw system were interviewed regarding pregnancies, child delivery, method of pain control during delivery, and any long-term outcome after delivery. In addition, sexual dysfunction (Female Sexual Distress Scale-Revised [FSDS]), depression (the Beck Depression Assessment Questionnaire), and Scoliosis Research Society 24 (SRS24) questionnaires were administered. Data was compared between patients with AIS without a history of pregnancy and healthy controls. Results Satisfaction with surgery in the AIS pregnant group using the SRS24 questionnaire scored 3.76/5 (p = 0.0047 when compared with nonpregnant AIS group). Six of the 17 of the women with AIS had severe back pain during pregnancy (35%) mandating home treatment or hospitalization. Of the 17 women, 13 complained of a sustained back pain after child delivery (76%) that impacted their life. In the nonscoliosis group, no back pain attributed to pregnancy was reported. The rates of regional anesthesia prescription among pregnant patients with AIS who underwent correction surgery was 30% (5/17), whereas among healthy pregnant women, rates were 100% (6/6). The SRS24 scores in the patients with AIS were 72% (88/120), showing a low score of 3.69/5 in the pain domains (p = 0.0048 when compared with nonpregnant patients with AIS). Depression rates were in the normal range and similar in all groups. FSDS scores, used to assess sexual dysfunction, were 4.02 in the pregnancy group and 5.67 in the nonpregnant group (not significant) and 4.6 in the nonscoliosis control group (not significant). Conclusion Women who underwent scoliosis correction suffered from long-term back pain after pregnancy and had decreased satisfaction with surgery. In addition, anesthesiologists refused epidurals in a large number of these patients. A larger study is needed on the topic.

Evidence for the adverse effect of starvation on bone quality: a review of the literature

Malnutrition and starvation's possible adverse impacts on bone health and bone quality first came into the spotlight after the horrors of the Holocaust and the ghettos of World War II. Famine and food restrictions led to a mean caloric intake of 200-800 calories a day in the ghettos and concentration camps, resulting in catabolysis and starvation of the inhabitants and prisoners. Severely increased risks of fracture, poor bone mineral density, and decreased cortical strength were noted in several case series and descriptive reports addressing the medical issues of these individuals. A severe effect of severely diminished food intake and frequently concomitant calcium- and Vitamin D deficiencies was subsequently proven in both animal models and the most common cause of starvation in developed countries is anorexia nervosa. This review attempts to summarize the literature available on the impact of the metabolic response to Starvation on overall bone health and bone quality.

The effect of 3-column spinal osteotomy on anterior pelvic plane and acetabulum position

Because the spine and pelvis are integrated, changes in spine sagittal balance affect relative acetabulum position. A 1° change of the anterior pelvic plane changes acetabulum anteversion by 0.8°. Three-column spine osteotomies correct fixed sagittal plane deformity. Twenty patients with kyphotic deformity and associated sagittal imbalance underwent corrective 3-column osteotomy. We reviewed upright pelvic and spine radiographs preoperatively and postoperatively and documented the changes in angles. The average sagittal vertical axis was 11.07 cm preoperatively and 4.8 cm postoperatively. Lumbar lordosis changed (on average) from 39° preoperatively to 55° postoperatively (P < .05). Sacral slope increased an average of 6.7° (P = .015). Pelvic tilt decreased by 5.4° (P = .001). The anterior pelvic plane increased by 8.23° (P < .0001). This correction of the sagittal balance is associated with a concomitant increase in sacral slope, pelvic tilt, and the anterior pelvic plane angles. These changes will increase acetabulum anteversion by a predicted 6.54°. This increase will change acetabular cup position and must be considered in patients with spine and pelvic osteoarthritis that requires hip surgery.

Israeli medical students' perceptions of six key medical specialties

BACKGROUND

Choosing a medical specialty requires medical students to match their interests and social-cultural situations with their perceptions of the various specialties.

OBJECTIVES

Examine Israeli 6th-year medical students' perceptions of six key specialties: pediatrics, orthopedic surgery, anesthesiology, obstetrics/gynecology, general surgery and family medicine.

METHODS

Questionnaires distributed to 355 6th-year students from three successive classes (2008-2010) of 6th-year students at the Hebrew University - Hadassah School of Medicine, Jerusalem, Israel and the 2010 class of the Ben Gurion University School of Medicine, Be'er Sheva, Israel.

RESULTS

Responses were obtained from 234 students, for a response rate of 66%. Pediatrics and obstetrics/gynecology were the specialties most often under positive career consideration by individual students. Anesthesiology and general surgery were least often under positive career consideration and were viewed as being in a workforce crisis. Pediatrics and family medicine, found to be especially popular among women, were perceived by 58% and 78% of respondents, respectively, as providing reasonable ratios of lifestyle to income. None of the students thought the same about general surgery and only 28% thought so about anesthesiology. Pediatrics and obstetrics/gynecology were reported to afford a controllable lifestyle by 63% and 8%, respectively, With respect to positive career considerations and lifestyle perceptions, there were no differences between the opinions of men and women students. Differences between genders arose in responses to queries of whether a specialty was interesting and challenging. Women were more likely than men to perceive pediatrics and family medicine as interesting and challenging while men were more likely to think that general and orthopedic surgery are interesting and challenging.

CONCLUSIONS

Knowing the medical students' perceptions of the various specialties should help in understanding the maldistribution of physicians among the various specialties. Such data can also be an important input into the efforts of the healthcare leadership to promote a specialty distribution that matches the population's evolving needs.

Disc degeneration after disc herniation: are we accelerating the process?

Study design: Systematic review.

Study rationale: Disc degeneration is a common process starting early in life. Often disc herniation is an early step in disc degeneration, which may cause pain or stenosis. How quickly this subsequent disc degeneration occurs following a disc herniation and subsequent surgical treatment and whether certain spinal procedures increase the rate of degeneration remain unclear.

Objectives: To investigate the risk of subsequent radiographic disc degeneration following discectomy, discography, and conservative care in patients with a first-time diagnosed herniated nucleus pulpous (HNP) and to ascertain whether this risk in these defined groups changes over time.

Methods: A systematic review of pertinent articles published up to June 2012. Key articles were searched to identify studies evaluating the risk of subsequent radiographic disc degeneration following treatment for HNP. Studies that included patients undergoing secondary surgery for disc herniation or that did not use a validated classification system to measure the severity of disc degeneration were excluded. Two independent reviewers assessed the strength of evidence using the GRADE criteria and disagreements were resolved by consensus.

Results: From a total of 147 possible citations, three cohort studies (class of evidence III) met our inclusion criteria and form the basis for this report. The risk of subsequent lumbar disc degeneration following standard discectomy was significantly greater compared with both microdiscectomy (48.7% vs 9.1%) and asymptomatic controls (90% vs 68%) in two studies with mean follow-ups of 5.5 and 25.3 years, respectively. Following conservative care for first-time HNP in the third study, the risk of progression of lumbar disc degeneration was 47.6% over the first 2 years of follow-up and 95.2% over the next 6 years of follow-up. In the same study, the risk of lumbar disc degeneration was shown to increase incrementally over the course of the 8-year follow-up, with all patients showing signs of degeneration at final examination.

Conclusion: Standard discectomy in first-time lumbar HNP may increase the risk of subsequent same-level lumbar disc degeneration compared with microdiscectomy as seen in one low-quality study. However, disc degeneration is likely a natural, temporal consequence following HNP, as demonstrated in a second low-quality study. The overall strength of evidence for the conclusions is very low.

Modular 'click-in-emulsion' bone-targeted nanogels

A new class of nanogel demonstrates modular biodistribution and affinity for bone. Nanogels, ∼70 nm in diameter and synthesized via an astoichiometric click-chemistry in-emulsion method, controllably display residual, free clickable functional groups. Functionalization with a bisphosphonate ligand results in significant binding to bone on the inner walls of marrow cavities, liver avoidance, and anti-osteoporotic effects.

Cement augmentation in spinal tumors: a systematic review comparing vertebroplasty and kyphoplasty

Study design: Comparative effectiveness review.

Study rationale: The spine is among the most common location for bony metastases. In many cases these metastases cause fractures leading to increased morbidity. Percutaneous cement augmentation techniques have been developed over the past decades for the treatment of these fractures; however, there are little data comparing these interventions.

Clinical question: Do comparative studies of vertebral cement augmentation for fractures caused by spinal tumors provide evidence of improved patient outcomes?

Methods: A systematic search and review of the literature was undertaken to identify studies published through June 8, 2011. Two individuals independently reviewed articles based on inclusion and exclusion criteria which were set a priori. Each article was evaluated using a predefined quality-rating system and an overall strength of evidence determined.

Results: The literature consists primarily of case series. Only two studies comparing vertebroplasty with kyphoplasty were found. Pain scores in both treatment groups were significantly decreased relative to preoperative scores and appear to have been sustained at follow-up times to 1 year. It is unclear whether one treatment provided superior pain relief than the other. Both studies reported decreased analgesic use after both treatments but neither study compared use between treatment groups. Balloon rupture occurred in one kyphoplasty patient in one study and extravasation of polymethylmethacrylate (PMMA) cement into the anterior perivertebral soft tissue was seen in another patient in the vertebroplasty group and no patients in the kyphoplasty group in the other study. No other intraoperative or postoperative complications occurred.

Conclusions: There is only limited evidence from comparative studies (two small retrospective cohort studies) regarding the benefits of vertebroplasty versus kyphoplasty in patients with spinal fractures caused by tumors. Both appear to be effective in reducing pain with relatively few complications. Whether one method provides superior results over the other cannot be determined from the available evidence. Study limitations preclude making definitive conclusions. The overall strength of evidenced is very low.

Medical specialty considerations by medical students early in their clinical experience

Background

Specialty selection by medical students determines the future composition of the physician workforce. Selection of career specialties begins in earnest during the clinical rotations with exposure to the clinical and intellectual environments of various specialties. Career specialty selection is followed by choosing a residency program. This is the period where insight into the decision process might help healthcare leaders ascertain whether, when, and how to intervene and attempt to influence students' decisions. The criteria students consider important in selecting a specialty and a residency program during the early phases of their clinical rotations were examined.

Methods

Questionnaires distributed to fifth-year medical students at two Israeli medical schools.

Results

229 of 275 (83%) questionnaires were returned. 80% of the students had considered specialties; 62% considered one specialty, 25% two, the remainder 3-5 specialties. Students took a long-range view; 55% considered working conditions after residency more important than those during residency, another 42% considered both equally important. More than two-thirds wanted an interesting and challenging bedside specialty affording control over lifestyle and providing a reasonable relationship between salary and lifestyle. Men were more interested in well-remunerated procedure-oriented specialties that allowed for private practice. Most students rated as important selecting a challenging and interesting residency program characterized by good relationships between staff members, with positive treatment by the institution, and that provided much teaching. More women wanted short residencies with few on-calls and limited hours. More men rated as important residencies affording much responsibility for making clinical decisions and providing research opportunities. More than 50% of the students considered it important that their residency be in a leading department, and in a large university medical center. Only 5% considered it important to do their residency in the country's peripheral areas, while 30% reported interest in a residency in the country's center.

Conclusions

The fifth year of a six-year medical school is an opportune time to provide students with information and guidance on the various specialties and selecting a residency program as they begin to solidify their perceptions and ideas about the various specialties. This study serves as an impetus to medical educators and healthcare leaders to become interested in students' career selection.

Benefits of a simple glycaemic protocol in an orthopaedic surgery ward: a randomized prospective study

BACKGROUND

Hyperglycaemia and diabetes mellitus are common in patients hospitalized in the orthopaedic surgery ward. However, glycaemic control obtained during hospitalization is often suboptimal. No method for achieving adequate glycaemic control in this population has been validated in an in-hospital setting.

INTERVENTION

An intervention including an intensive subcutaneous insulin protocol in the orthopaedic department.

METHODS

All diabetic patients admitted to the Department of Orthopaedic Surgery were prospectively randomized during a 6-month period. One group (n = 30) received standard care with sliding scale insulin and the other group (n = 35) received the intervention protocol. During the intervention period, the staff was briefed on the importance of glucose monitoring and control. An intensive multiple-injection protocol consisting of four daily regular/neutral protamine hagedorn (NPH) insulin injections was initiated in diabetic patients. The programme was followed up by a consulting diabetologist.

RESULTS

Mean blood glucose levels throughout the hospitalization were 161.48 ± 3.8 mg/dL in the intervention group versus 175.29 ± 2.3 mg/dL in the control group (p < 0.0005). Hospitalization was shorter by 2 days in the intervention group (p < 0.05). The number of severe hyperglycaemic events (blood glucose level above 400 mg%) was significantly lower (p < 0.05) in the intervention group. There was no significant difference in the number of hypoglycaemic events.

CONCLUSIONS

The suggested four-step intervention regimen improved glycaemic control of hospitalized patients in the orthopaedic department and simplified the 'in-house' treatment of the diabetic patient. Hospital stays were reduced on average by two days (p < 0.05).

Does pregnancy increase curve progression in women with scoliosis treated without surgery?

Study design: Systematic review.

Study rationale: It is commonly believed that scoliosis treated nonoperatively does not worsen in pregnancy; however, at times patients with scoliosis progress rapidly during these months.

Objective or clinical question: What is the level of evidence to support or deny the claim that scoliosis treated nonoperatively does not worsen in pregnancy?

Methods: A systematic review of the literature was undertaken for articles published through March 2011. PubMed, Cochrane, National Guideline Clearinghouse Databases as well as bibliographies of key articles were searched. Two independent authors reviewed articles. Inclusion and exclusion criteria were set and each article was subject to a predefined quality-rating scheme.

Results: We identified two articles meeting our inclusion criteria. There was no difference in risk of curve progression > 5° or > 10° between women who had one or more pregnancies compared with those who had never been pregnant. However, among women who had been treated with an orthosis, those with one or more pregnancies had a higher risk of curve progression > 5° compared with never-pregnant women: relative risk = 8.1 (95% confidence interval: 1.8–35.8) in one study and 1.9 (95% confidence interval: 0.8–4.3) in the other. While women with more severe curves had a higher risk of curve progression, having one or more pregnancies did not appear to modify the effect of curve severity.

Conclusions: Having one or more pregnancies does not appear to affect curve progression in scoliosis. However, among patients who had prior orthotic treatment, there is some evidence to suggest that women experiencing one or more pregnancies had a higher risk of curve progression compared with never-pregnant women. The overall strength of evidence for this conclusion is low.

Tissue engineering approaches for bone repair: concepts and evidence

Over the last decades, the medical world has advanced dramatically in the understanding of fracture repair. The three components needed for fracture healing are osteoconduction, osteoinduction and osteogenesis. With newly designed scaffolds, ex vivo produced growth factors and isolated stem cells, most of the challenges of critical size bone defects have been resolved in vitro, and in some cases in animal models as well. However, there are still challenges needed to be overcome before these technologies can be fully converted from the bench to the bedside. These technological and biological advancements need to be converted to mass production of affordable products that can be used in every part of the world. Vascularity, full substation of scaffolds by native bone, and bio-safety are the three most critical steps to be challenged before reaching the clinical setting.

Interspinous devices: are they as attractive as they seem? An intermediate-term follow-up

Study design: A retrospective cohort of 68 patients who underwent insertion of the DIAM (Medtronic Sofamor Danek, Switzerland) interspinous device (ISD) during 2006–2008 at one medical center.

Objectives: To assess the short- and intermediate-term outcomes and complications associated with ISD.

Methods: Evaluation of files and all patients who underwent insertion of a DIAM ISD was performed. Patients walking distances and pain (visual analog scale score) were compared with data gathered before surgery. Outcome and all complications related to ISD have been identified and analyzed.

Results: All 68 patients were available for follow-up. Mean follow-up was 34 months (23–52 months). The average age was 57 (±13) years. Walking distance increased by 890% and patient's pain score improved by 3.27 points on visual analog scale. Twenty-one (32%) of the 68 patients had perioperative or late complications. Nine complications (75%) were unrelated to ISD and included 5 dura tears, 3 wound-related complications, and 1 transient ischemic attack. Spinous process fractures occurred in 5 cases, leading to revision in 2 cases. In total, 7 of the patients required revision surgery. These patients were older, with an average age of 69 years.

Conclusion: The outcome of patients who had an implantation of the DIAM ISD is good. In this cohort, 6% developed recurrent claudication symptoms in the second postoperative year. In an older population, the combination of softer bone and rigid stenosis increase the risk of spinous process fracture, resulting in failure and leading to revision surgery. Other solutions should be sought for these patients.

Long-term outcome of surgical correction of congenital kyphosis in patients with myelomeningocele (MMC) with segmental spino-pelvic fixation

Study design: A retrospective case series of patients with myelomeningocele (MMC) who underwent kyphectomy and posterior segmental fixation using Luque rods and 16-gauge wires.

Objective: To assess outcomes after posterior kyphectomy and segmental fixation for kyphosis in patients with MMC.

Methods: Thirteen consecutive patients who underwent posterior kyphectomy for transforaminal fixation contiguous to “everted lamina.” Fusion rates, time to fusion, change in Cobb angle, complications, and improvement in activities of daily living using the Katz score were measured.

Results: Average age at time of surgery was 9.2 (range, 4.5–17) years. Average time to follow-up was 120 (range, 20–310) months. Solid fusion was achieved in 9 patients (69%) with a mean time to fusion of 12 months. The mean postoperative kyphotic curve was 22° with an average correction of 90°. Five patients (38%) experienced a postoperative complication. The mean improvement in activities of daily living score was 1.6 points and all patients achieved independent sitting balance.

Conclusion: Segmental spino-pelvic fixation is a solid alternative mode of fixation in patients with MMC with congenital kyphosis. Patient selection, proper perioperative multidisciplinary assessment, and surgeons' expertise are significant in the success of this complex surgery.

Migrating shrapnel: a rare cause of knee synovitis

Shrapnel injuries in soft tissues often do not require surgical excision. Metals that remain embedded in the surrounding tissue are not thought to cause significant damage and the patients are generally asymptomatic. This case presentation describes a patient who sustained a penetrating shrapnel injury to his thigh, where the metal fragment was not removed. However, more than 20 years later, the patient developed knee synovitis. On X-ray the shrapnel was seen in the suprapatellar pouch. An arthroscopy was preformed and the shrapnel was removed with full healing of the patient.

CONCLUSION

although nonsurgical treatment of shrapnel in soft tissues is the treatment of choice in many cases, late migration is possible, causing distal symptoms and may require surgical excision.

Evaluation of the biotic ligand model to predict long-term toxicity of nickel to Hyalella azteca

Three models were developed and evaluated for their ability to predict long-term bioaccumulation of nickel (Ni) and its toxicity to Hyalella azteca using data from 28-d toxicity tests. One of the models was based on competitive action of Ni with Ca and H (the biotic ligand model; BLM), and the other two models included expressions for the potential noncompetitive action of calcium on the ligand (i.e., acclimation), in addition to, or instead of, its competitive action (not accounted for in the BLM). Each model was able to predict lethal accumulation 50 (accumulation at 50% mortality; LA50s) within a factor of 2 of the corresponding observed LA50. The mean predicted LA50 from all three models was within 13% of the observed mean LA50 of 0.90 µmol/g (dry weight). The median lethal concentrations (LC50s) predicted by the three models were similar and were within a factor of 2 of the observed LC50s for 11 of 13 tests, providing encouragement for further development of a long-term Ni BLM. The similar performance of models based on competitive or noncompetitive action may reflect limitations in the data set or may suggest that effects of calcium on the ligand (L(T)) were insufficient to hamper the functionality of the competitive model or that the LA50/L(T) ratio, rather than the LA50 and L(T), is constant.

[Orthopedic care in polytrauma patients in the setting of a multi-casualty event]

Multi-casualty events are characterized by a large number of wounded people arriving at trauma centers in a short period of time. These wounded suffer distinctive injuries in accordance with the cause of the event. Close to 50 percent of all injuries in a multi-casualty event are musculoskeletal injuries. These injuries are not usually isolated and indicate that the patient has suffered severe trauma. Correct management of such an event requires proper management in the pre-hospital, trauma centers, wards and operating galleries. A "damage control" policy should be implemented in all stages of the patient's care. Orthopedic care has been revolutionized several times--developing from delayed care, to early total care and finally to "damage control" orthopedics. "Damage control" orthopedics emphasizes initial stabilization and control of injuries, due to the systemic cytokine storm after polytrauma, prior to final corrective surgery of the patient's fractures. In this article the authors review the orthopedic care in a multi-casualty event, and the specific care given to each of the wounded in such an event.

The current state in the evaluation and treatment of ARdS and SIRS

Trauma, the number one cause of death until the fourth decade of life, causes an inflammatory response. This response in its extreme is associated with the development of the systemic inflammatory state, adult respiratory distress syndrome, multi-organ failure, and death. The inflammatory response is mediated via multiple pathways- the inflammatory-cytokine, immunologic, coagulation and endocrine pathways. It is countered by producing antiinflammatory mediators. This reaction is altered in elderly patients. Knowledge of the patient's prior medical problems and the differential diagnosis for the possible causes of the current condition should help direct the surgical intervention and supportive care in an attempt to stabilize the patient. With the improvement of monitoring and diagnostic technologies, understanding the significance of the inflammatory pathways in trauma patients will decrease morbidity and mortality in this group of patients.

Functional co-assembly among subunits of cyclic-nucleotide-activated, nonselective cation channels, and across species from nematode to human

Cyclic-nucleotide-activated, nonselective cation channels have a central role in sensory transduction. They are most likely tetramers, composed of two subunits (alpha and beta or 1 and 2), with the former, but not the latter, being able to form homomeric cyclic-nucleotide-activated channels. Identified members of this channel family now include, in vertebrates, the rod and cone channels mediating visual transduction and the channel mediating olfactory transduction, each apparently with distinct alpha- and beta-subunits. Homologous channels have also been identified in Drosophila melanogaster and Caenorhabditis elegans. By co-expressing any combination of two alpha-subunits, or alpha- and beta-subunits, of this channel family in HEK 293 cells, we have found that they can all co-assemble functionally with each other, including those from fly and nematode. This finding suggests that the subunit members so far identified form a remarkably homogeneous and conserved group, functionally and evolutionarily, with no subfamilies yet identified. The ability to cross-assemble allows these subunits to potentially generate a diversity of heteromeric channels, each with properties specifically suited to a particular cellular function.

Social anxiety and performance in an interpersonal perception task

The Interpersonal Perception Task-15 videotape served as a criterion measure to test hypotheses about individual differences in interpersonal perception. 160 undergraduates completed the Personal Report of Communication Apprehension Scale, the Shyness and Sociability Scale, and the Interpersonal Perception Task-15. Scores on the Communication Apprehension Scale were negatively correlated with Interpersonal Perception Task-15 scores, as predicted. Scores on the Shyness scale were negatively correlated with scores on the Interpersonal Perception Task-15, while Sociability scale scores were positively correlated. These results underscore the association between social anxiety and interpersonal perception.

Inhibition of Ca2+ currents by a mu-opioid in a defined subset of rat sensory neurons

Activation of the endogenous opioid system can suppress pain without affecting other sensations, but the cellular mechanism of this selectivity is unclear. The analgesia might be due to inhibitory synapses arranged only on neurons whose activity leads to pain sensations. Alternatively, opioids might be released broadly, with neurons involved in pain sensation being especially sensitive. Therefore, we asked whether different subsets of rat dorsal root ganglion (DRG) sensory neurons vary in their sensitivity to opioids. Dissociated neurons were subdivided according to the spinal laminae to which they likely had projected, and whether they had innervated muscle. Using the patch-clamp method, we measured the inhibition of Ca2+ current by DAGO (Tyr-D-Ala-Gly-MePhe-Gly-ol), a peptide that selectively activates the mu (morphine) receptor. We also investigated the presence of different types of Ca2+ channels. In DRG neurons chosen at random, Ca2+ currents were inhibited by DAGO to widely varying degrees, with an average inhibition of 38%. Ca2+ currents in neurons in a subset that projects to laminae I and II had a lower average inhibition, and unlike the randomly selected cells, the responses were predictable and tightly distributed about the mean. This indicates that the variability of opioid sensitivity among DRG neurons reflects the presence of different subsets of cells. Since neurons projecting to laminae I and II, the projection site of nociceptive neurons, did not show high opioid sensitivity, there is no evidence that nociceptive neurons have stronger responses to opioids. But a firm conclusion is impossible because projection site does not strictly define sensory modality.

Activation of mu opioid receptors inhibits transient high- and low-threshold Ca2+ currents, but spares a sustained current

Opioids and opiates decrease the duration of action potentials and the amount of neurotransmitter released from sensory neurons. The mu-type opioid receptor, the binding site for morphine, is thought to act exclusively on K+ channels. Here, we show that activation of the mu receptor inhibits Ca2+ channels in rat sensory neurons; the effect is blocked by a mu antagonist and is not mimicked by kappa or delta receptor agonists. Both low-threshold (T-type) and high-threshold Ca2+ currents are partially suppressed. omega-Conotoxin-sensitive and omega-conotoxin-insensitive, high-threshold Ca2+ currents are inhibited. The kinetic effect on high-threshold current is like that caused by diminished rest potential: the transient component is selectively lost, whereas the sustained component is spared.

Two components of high-threshold Ca2+ current inactivate by different mechanisms

High-threshold Ca2+ current triggers neurotransmitter release, but the existence, significance, and correct identification of different types of high-threshold Ca2+ channels remain controversial. We show selective inhibition of a rapidly inactivating component of high-threshold Ca2+ current in rat sensory neurons by bursts of brief pulses that mimic trains of action potentials and by prolonged depolarization just above the normal rest potential. In contrast, a slowly inactivating component decreases only when sufficient Ca2+ accumulates within the cell. Thus, there are physiologically important differences: whereas availability of the transient component depends on the value of the rest potential and the pattern of a prior stimulus, the sustained component seems to provide a baseline level of voltage-dependent Ca2+ entry that is lost only when intracellular Ca2+ rises.

T-type calcium channels: heterogeneous expression in rat sensory neurons and selective modulation by phorbol esters

We report selective inhibition of low-threshold, T-type calcium channels by a phorbol ester in rat sensory neurons. Cells were exposed, either acutely or with 15-60 min preincubations, to low concentrations of phorbol 12-myristate 13-acetate, (PMA), an activator of protein kinase C; if the temperature was 29 degrees C or higher, T-type Ca current was diminished without effect on high-threshold Ca current. In untreated cells, the amplitude of T-type Ca current varies widely among neighboring sensory neurons. T channels are absent in about 25% of cells, provide a small current near threshold for the majority of cells, and are a dominant pathway for calcium entry in a small subset of neurons. The results are of interest because, by selectively inhibiting a calcium channel expressed differently among subpopulations of sensory neurons, activation of protein kinase C might selectively suppress particular sensations.

Imaginary representations of time cycles

Two studies and 2 experiments, designed to investigate visual imaginary representations for day, week, and year time cycles, were reported. Incidence of such representations, incidence of subjective distortion, and two sources of suggestibility were also investigated. Finally, a relationship was sought between clearness of visual representations and performance on time-related tasks. Results indicated a high incidence of representations for all three time cycles. The representations were generally reported to be self-constructed as opposed to being taught. Subjective distortions were found in all three time cycles. Presence of an example increased the likelihood of a representation, indicating a possible source of suggestibility. Type of example was shown to have little influence on probability or content. Significant correlations were found between clearness of representation and self-reported accuracy of time estimation. This correlation was supposed by the finding that a group of subjects with clear visual representations out-performed a group of subjects with no representation on backward temporal calculations for months of the year. Results were discussed in terms of their implications for cognitive psychology and future research.

Extroversion and reminiscence following a frustrating paired-associate task

Two experiments were reported relating extroversion to reminiscence following a frustrating paired-associate (PA) task. In the first experiment a group of 30 male and female college students was randomly assigned to one of two tasks in which they learned a PA list of high or low stimulus similarity. All PA lists were mixed lists composed of half solvable and half unsolvable (randomized) stimulus-response items. Recall for solvable items was tested immediately, 15 min, and 30 min after criterion was reached. Results indicated a significant difference between high and low stimulus similarity with superior recall for low similarity. The predicted reminiscence effect for high stimulus similarity recall was present but not significant. Comparison of recall scores for extroverts and introverts indicated a significant difference in recall favoring the introverts. The second experiment made a similar test of recall for two groups of S s that had been established as extreme extroverts or introverts (N = 8 in each group). The superiority of recall for introverts was replicated, and a reminiscence effect was found for the extroverts. Results were discussed in relation to Eysenck's formulation and previous conflicting results.