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van Niekerk M, O'Mara A, Kha S, Zhou J, McAdams TA, Ladd A, Shea K, Frick S, Maloney WJ, Chu CR. Strengthening the Pipeline: Promoting Diversity into Orthopedic Surgery. Clin Sports Med 2024; 43:253-270. [PMID: 38383108 DOI: 10.1016/j.csm.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
The United States is a nation of diverse racial and ethnic origins. Athletes represent the full spectrum of the nation's population. However, the orthopedic surgeons who serve as team physicians are Caucasian and male with staggeringly few exceptions. This manuscript provides an overview of the current status and barriers to diversity among orthopedic team physicians, along with strategies to address the issue. Specifically, pipeline initiatives implemented at one academic medical school and orthopedic surgery department are summarized as potential models that can be further developed by other institutions to enhance diversity in orthopedic surgery.
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Affiliation(s)
- Maike van Niekerk
- Department of Orthopedic Surgery, Stanford University, Stanford, CA, USA
| | - Alana O'Mara
- Department of Orthopedic Surgery, Stanford University, Stanford, CA, USA
| | - Stephanie Kha
- Department of Orthopedic Surgery, Stanford University, Stanford, CA, USA
| | - Joanne Zhou
- Department of Orthopedic Surgery, Stanford University, Stanford, CA, USA
| | - Timothy A McAdams
- Department of Orthopedic Surgery, Stanford University, Stanford, CA, USA
| | - Amy Ladd
- Department of Orthopedic Surgery, Stanford University, Stanford, CA, USA
| | - Kevin Shea
- Department of Orthopedic Surgery, Stanford University, Stanford, CA, USA
| | - Steven Frick
- Department of Orthopedic Surgery, Stanford University, Stanford, CA, USA
| | - William J Maloney
- Department of Orthopedic Surgery, Stanford University, Stanford, CA, USA
| | - Constance R Chu
- Department of Orthopedic Surgery, Stanford University, Stanford, CA, USA.
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Mabudian L, D'Agostino RB, Jordan JH, Martin MB, Fleshman JA, Crotts T, Ladd A, Olson K, Weaver KE, Hackney MH, Hundley WG. Accuracy of Rapid Cardiovascular Magnetic Resonance Assessment of Left Ventricular Function During Community Cancer Cardiotoxicity Surveillance (WF98213). Am J Cardiol 2023; 205:204-206. [PMID: 37611411 DOI: 10.1016/j.amjcard.2023.07.176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 07/26/2023] [Accepted: 07/31/2023] [Indexed: 08/25/2023]
Affiliation(s)
- Leila Mabudian
- Virginia Commonwealth University Pauley Heart Center, Division of Cardiology, Richmond, Virginia
| | - Ralph B D'Agostino
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jennifer H Jordan
- Virginia Commonwealth University Pauley Heart Center, Division of Cardiology, Richmond, Virginia; Department of Biomedical Engineering, Virginia Commonwealth University, Richmond, Virginia
| | - Madalyn B Martin
- Virginia Commonwealth University Pauley Heart Center, Division of Cardiology, Richmond, Virginia
| | - Julia A Fleshman
- Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Teresa Crotts
- Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Amy Ladd
- Virginia Commonwealth University Pauley Heart Center, Division of Cardiology, Richmond, Virginia
| | - Kristine Olson
- Virginia Commonwealth University Pauley Heart Center, Division of Cardiology, Richmond, Virginia
| | - Kathryn E Weaver
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Mary Helen Hackney
- Department of Hematology, Oncology, and Palliative Care, Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia
| | - W Gregory Hundley
- Virginia Commonwealth University Pauley Heart Center, Division of Cardiology, Richmond, Virginia; Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina.
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Suddala S, O’Connell N, D’Agostino R, Ladd A, Lucas AR, Jordan JH, Salloum FN, Ky B, Hackney MH, Hundley WG. Reduced Thoracic Aortic Distensibility Upon Breast Cancer Diagnosis (WF-97415 and WF-98213). JACC CardioOncol 2023; 5:704-706. [PMID: 37969653 PMCID: PMC10635869 DOI: 10.1016/j.jaccao.2022.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | - W. Gregory Hundley
- Virginia Commonwealth University School of Medicine, PO Box 980335, Richmond, Virginia 23298-0335, USA @VCUHealthHeart@oscardneufville@greghundleymd
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Kron J, Crawford T, Bogun F, Jordan JH, Koelling T, Syed H, Syed A, Iden T, Polly K, Federmann E, Bray K, Lathkar-Pradhan S, Ladd A, Dickson VM, Barron A, Tavoos A, Beanlands R, Birnie D, Ellenbogen K, Van Tassell BW, Hundley WG, Abbate A. Interleukin-1 Blockade in Cardiac Sarcoidosis: A Pilot Study. Circ Arrhythm Electrophysiol 2023; 16:e011869. [PMID: 37092332 PMCID: PMC10192113 DOI: 10.1161/circep.123.011869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Affiliation(s)
| | - Thomas Crawford
- Cardiovascular Center, University of Michigan, Ann Arbor, MI
| | - Frank Bogun
- Cardiovascular Center, University of Michigan, Ann Arbor, MI
| | | | - Todd Koelling
- Cardiovascular Center, University of Michigan, Ann Arbor, MI
| | | | | | | | | | | | - Kirsta Bray
- Cardiovascular Center, University of Michigan, Ann Arbor, MI
| | | | | | | | | | - Anahita Tavoos
- Dept of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Canada
| | - Rob Beanlands
- Dept of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Canada
| | - David Birnie
- Dept of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Canada
| | | | - Benjamin W. Van Tassell
- VCU Pauley Heart Center
- Dept of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA
| | | | - Antonio Abbate
- Robert M. Berne Cardiovascular Research Center & Division of Cardiology – Heart and Vascular Center, University of Virginia, Charlottesville, VA
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Bellissimo MP, Reding K, Workman S, Mabudian L, OConnell N, Heiston E, Ladd A, Dagostino R, Weaver KE, Lesser GJ, Fuemmeler B, Hundley WG. CHANGES IN INTRAMUSCULAR FAT ARE RELATED TO REDUCED LEFT VENTRICULAR EJECTION FRACTION DURING CANCER THERAPY (PREVENT WF-98213). J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)02572-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Putnam JG, Kerkhof FD, Shah K, Richards AW, Ladd A. Helping Surgeons' Hands: A Biomechanical Evaluation of Ergonomic Instruments. J Hand Surg Am 2023:S0363-5023(22)00767-5. [PMID: 36746690 DOI: 10.1016/j.jhsa.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 11/29/2022] [Accepted: 12/14/2022] [Indexed: 02/08/2023]
Abstract
PURPOSE "Ergonomic" is a common descriptor for a desk or computer workspace but is a term rarely used to describe a surgical instrument. Instead, surgeons spend many hours in inconvenient positions, often using instruments that are not ergonomic. Improving the ergonomics of surgical instruments may decrease the required force for simple tasks and allow for more efficient surgery. METHODS To evaluate the impact of ergonomic surgical instruments, the authors developed ergonomic screwdriver handles. The shape and size of these handles were engineered using previous dental studies and 3-dimensional modeling to create an ideal handle for specific glove sizes. Participants were recruited to test 3 different ergonomic handle sizes against a standard screwdriver while assessing digital peak force, digital contact area, and participant preference. Ten participants (3 women) with glove sizes ranging from 6 to 8 were evaluated. RESULTS Ergonomic screwdriver handles sized for glove sizes 6 and 7 required significantly less thumb peak force than the standard screwdriver for all participants (702 N for glove size 6 and 567 N for glove size 7 ergonomic screwdrivers, vs 1780 N for "one size fits all" standard screwdriver). Participants consistently preferred screwdrivers that required lower thumb and index finger forces. All ergonomic handles required lower thumb and index finger force. Eighty percent of participants preferred a screwdriver modeled within 1 glove size of their own. CONCLUSIONS Improved ergonomic handles require less force and are preferred by surgeons. CLINICAL RELEVANCE The significant decrease in thumb peak force for glove sizes 6 and 7 suggests that there is room for ergonomic improvement in instruments, especially for surgeons with smaller hands. Manufacturing ergonomic screwdriver handles and using the evolving convenience of 3-dimensional printing may help to develop a more comfortable work environment for surgeons.
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Affiliation(s)
- Jill G Putnam
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Redwood City, CA.
| | - Faes D Kerkhof
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Redwood City, CA
| | - Kalpit Shah
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Redwood City, CA
| | - Alexander W Richards
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Redwood City, CA
| | - Amy Ladd
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Redwood City, CA
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Dong M, Kerkhof F, Deleu G, Vereecke E, Ladd A. Using a finite element model of the thumb to study Trapeziometacarpal joint contact during lateral pinch. Clin Biomech (Bristol, Avon) 2023; 101:105852. [PMID: 36521409 DOI: 10.1016/j.clinbiomech.2022.105852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 11/26/2022] [Accepted: 12/01/2022] [Indexed: 12/10/2022]
Abstract
BACKGROUND Finite element (FE) analysis is widely used in different fields of orthopaedic surgery, however, its application to the trapeziometacarpal joint has been limited due to the small size, complex biconcave-convex joint geometry, and complex musculature. The goal of this study was to improve upon existing models by creating a muscle-driven FE thumb model and use the model to simulate the biomechanical effect of hand therapy exercises and ligament reconstructive surgeries. METHODS Bone and cartilage geometry were based on a CT dataset of a subject performing a static lateral pinch task. A previously validated musculoskeletal model was utilized to extract electromyography (EMG)-driven muscle forces. Five ligaments with biomechanical significance were modeled as springs using literature values and attached according to their anatomical landmarks. FINDINGS The biomechanical consequence of various interventions was proxied as a change in the maximum cartilage stress. The result shows tightening the dorsal ligament complex (dorsal radial ligament, dorsal central ligament, posterior oblique ligament) is the most effective, achieving a stress reduction of 4.8%. Five exercises used in hand therapies were modeled, among which thenar eminence strengthening showed the most prominent stress reduction of 4.0%. Four ligament reconstructive surgeries were modeled, with Eaton-Littler reconstruction showed the most significant stress reduction of 25.0%. INTERPRETATION Among the routinely utilized treatment options for early thumb osteoarthritis, we found that three methods: dorsal ligament imbrication, thenar eminence exercise, and the Eaton-Littler method may confer biomechanical advantages cartilage loading. These advantages align with the clinically observed favorable outcomes.
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Affiliation(s)
- Meilin Dong
- Stanford University School of Medicine, Stanford, CA, USA.
| | - Faes Kerkhof
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - GertJan Deleu
- Muscles & Movement, Biomedical Sciences Group, University of Leuven Campus Kulak, Kortrijk, Belgium
| | - Evie Vereecke
- Muscles & Movement, Biomedical Sciences Group, University of Leuven Campus Kulak, Kortrijk, Belgium
| | - Amy Ladd
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
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Kim SE, Pham NS, Park JH, Ladd A, Lee J. Potential biomechanical risk factors on developing lead knee osteoarthritis in the golf swing. Sci Rep 2022; 12:22653. [PMID: 36587045 PMCID: PMC9805371 DOI: 10.1038/s41598-022-27160-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 12/27/2022] [Indexed: 01/01/2023] Open
Abstract
The load on the lead knee joint during a golf swing is greater than that observed during gait. However, current evidence regarding golf swing biomechanics for risks associated with knee osteoarthritis (OA) is limited. Therefore, this study investigated golf swing styles associated with knee adduction and abduction moments, which are considered to be crucial loading regions of the medial and lateral compartments of knee OA, respectively. Thirteen professional male golfers performed five shots using a 5-iron club, and their swings were recorded using a motion capture system with two force platforms for the feet. A regression analysis was performed to calculate the correlation coefficients between the peak knee adduction and abduction moments of the lead leg and varus/valgus angle, toe-out angle, stance width, weight transfer, and shoulder sway. Swinging with a narrower stance width at address (r = - 0.62, p = 0.02) with more weight shift (r = 0.66, p = 0.014) and shoulder sway (r = 0.79, p = 0.001) towards the target during the downswing were associated with a higher peak knee adduction of the lead leg, whereas a greater valgus angle at address (r = 0.60, p = 0.03) was associated with a higher peak knee abduction of the lead leg. Based on these findings, we anticipate future research to support postural changes, particularly a wider stance width and restricted shoulder sway for golfers who are classified to be at high risk of developing medial compartment knee OA, as well as a lower valgus (tibial medial tilt) angle at address for those classified to be at high risk of developing lateral compartment knee OA.
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Affiliation(s)
- Sung Eun Kim
- grid.168010.e0000000419368956Department of Orthopaedic Surgery, Stanford University, Stanford, CA USA ,grid.414123.10000 0004 0450 875XMotion & Gait Analysis Laboratory, Lucile Packard Children’s Hospital, Palo Alto, CA USA
| | - Nicole Segovia Pham
- grid.168010.e0000000419368956Department of Orthopaedic Surgery, Stanford University, Stanford, CA USA
| | - Jae Hyeon Park
- grid.412145.70000 0004 0647 3212Department of Rehabilitation Medicine, Hanyang University Guri Hospital, Guri-Si, Gyeonggi-Do Korea
| | - Amy Ladd
- grid.168010.e0000000419368956Department of Orthopaedic Surgery, Stanford University, Stanford, CA USA
| | - Jangyun Lee
- grid.470090.a0000 0004 1792 3864Department of Orthopedic Surgery, 6-01 Dongguk University Ilsan Hospital, 27 Dongguk Ro, Ilsandong-Gu, Goyang-Si, 10326 Gyeonggi-Do Korea ,grid.31501.360000 0004 0470 5905Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Korea
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9
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Zhou JY, Richards A, Schadl K, Ladd A, Rose J. The swing performance Index: Developing a single-score index of golf swing rotational biomechanics quantified with 3D kinematics. Front Sports Act Living 2022; 4:986281. [PMID: 36619352 PMCID: PMC9816382 DOI: 10.3389/fspor.2022.986281] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 11/30/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction Golf swing generates power through coordinated rotations of the pelvis and upper torso, which are highly consistent among professionals. Currently, golf performance is graded on handicap, length-of-shot, and clubhead-speed-at-impact. No performance indices are grading the technique of pelvic and torso rotations. As an initial step toward developing a performance index, we collected kinematic metrics of swing rotational biomechanics and hypothesized that a set of these metrics could differentiate between amateur and pro players. The aim of this study was to develop a single-score index of rotational biomechanics based on metrics that are consistent among pros and could be derived in the future using inertial measurement units (IMU). Methods Golf swing rotational biomechanics was analyzed using 3D kinematics on eleven professional (age 31.0 ± 5.9 years) and five amateur (age 28.4 ± 6.9 years) golfers. Nine kinematic metrics known to be consistent among professionals and could be obtained using IMUs were selected as candidate variables. Oversampling was used to account for dataset imbalances. All combinations, up to three metrics, were tested for suitability for factor analysis using Kaiser-Meyer-Olkin tests. Principal component analysis was performed, and the logarithm of Euclidean distance of principal components between golf swings and the average pro vector was used to classify pro vs. amateur golf swings employing logistic regression and leave-one-out cross-validation. The area under the receiver operating characteristic curve was used to determine the optimal set of kinematic metrics. Results A single-score index calculated using peak pelvic rotational velocity pre-impact, pelvic rotational velocity at impact, and peak upper torso rotational velocity post-impact demonstrated strong predictive performance to differentiate pro (mean ± SD:100 ± 10) vs. amateur (mean ± SD:82 ± 4) golfers with an AUC of 0.97 and a standardized mean difference of 2.12. Discussion In this initial analysis, an index derived from peak pelvic rotational velocity pre-impact, pelvic rotational velocity at impact, and peak upper torso rotational velocity post-impact demonstrated strong predictive performance to differentiate pro from amateur golfers. Swing Performance Index was developed using a limited sample size; future research is needed to confirm results. The Swing Performance Index aims to provide quantified feedback on swing technique to improve performance, expedite training, and prevent injuries.
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Affiliation(s)
- Joanne Y. Zhou
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, United States
| | - Alexander Richards
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, United States
| | - Kornel Schadl
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, United States,Motion & Gait Analysis Lab, Lucile Packard Children's Hospital, Palo Alto, CA, United States
| | - Amy Ladd
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, United States,Motion & Gait Analysis Lab, Lucile Packard Children's Hospital, Palo Alto, CA, United States
| | - Jessica Rose
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, United States,Motion & Gait Analysis Lab, Lucile Packard Children's Hospital, Palo Alto, CA, United States,Correspondence: Jessica Rose
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Kerkhof F, Kenney D, Ogle M, Shelby T, Ladd A. The biomechanics of osteoarthritis in the hand: Implications and prospects for hand therapy. J Hand Ther 2022; 35:367-376. [PMID: 36509610 DOI: 10.1016/j.jht.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The unique anatomy of the human hand makes it possible to carefully manipulate tools, powerfully grasp objects, and even throw items with precision. These apparent contradictory functions of the hand, high mobility for manual dexterity vs high stability during forceful grasping, imply that daily activities impose a high strain on a relatively instable joint. This makes the hand susceptible to joint disorders such as osteoarthritis. Both systemic (eg, genetics, hormones) and mechanical factors (eg, joint loading) are important in the development of osteoarthritis, but the precise pathomechanism remains largely unknown. This paper focuses on the biomechanical factors in the disease process and how hand therapists can use this knowledge to improve treatment and research. CONCLUSION Multiple factors are involved in the onset and development of osteoarthritis in the hand. Comprehension of the biomechanics helps clinicians establish best practices for orthotics intervention, exercise, and joint protection programs even in de absence of clear evidence-based guidelines. The effect and reach of hand therapy for OA patients can be expanded substantially when intervention parameters are optimized and barriers to early referrals, access reimbursement, and adherence are addressed. Close and early collaboration between hand therapists and primary care, women's health, rheumatology, and hand surgery providers upon diagnosis, and with hand surgeons pre and postoperatively, combined with advances in the supporting science and strategies to enhance adherence, appear to be a promising way forward.
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Affiliation(s)
- Faes Kerkhof
- Chase Hand and Upper Limb Center, Stanford University, Palo Alto, CA, USA.
| | - Deborah Kenney
- Chase Hand and Upper Limb Center, Stanford University, Palo Alto, CA, USA
| | - Miranda Ogle
- Chase Hand and Upper Limb Center, Stanford University, Palo Alto, CA, USA
| | - Tara Shelby
- Chase Hand and Upper Limb Center, Stanford University, Palo Alto, CA, USA
| | - Amy Ladd
- Chase Hand and Upper Limb Center, Stanford University, Palo Alto, CA, USA
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Van Tassell B, Mihalick V, Thomas G, Marawan A, Talasaz AH, Lu J, Kang L, Ladd A, Damonte JI, Dixon DL, Markley R, Turlington J, Federmann E, Del Buono MG, Biondi-Zoccai G, Canada JM, Arena R, Abbate A. Rationale and design of interleukin-1 blockade in recently decompensated heart failure (REDHART2): a randomized, double blind, placebo controlled, single center, phase 2 study. J Transl Med 2022; 20:270. [PMID: 35706006 PMCID: PMC9198622 DOI: 10.1186/s12967-022-03466-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 05/30/2022] [Indexed: 01/01/2023] Open
Abstract
Background Heart failure (HF) is a global leading cause of mortality despite implementation of guideline directed therapy which warrants a need for novel treatment strategies. Proof-of-concept clinical trials of anakinra, a recombinant human Interleukin-1 (IL-1) receptor antagonist, have shown promising results in patients with HF. Method We designed a single center, randomized, placebo controlled, double-blind phase II randomized clinical trial. One hundred and two adult patients hospitalized within 2 weeks of discharge due to acute decompensated HF with reduced ejection fraction (HFrEF) and systemic inflammation (high sensitivity of C-reactive protein > 2 mg/L) will be randomized in 2:1 ratio to receive anakinra or placebo for 24 weeks. The primary objective is to determine the effect of anakinra on peak oxygen consumption (VO2) measured at cardiopulmonary exercise testing (CPX) after 24 weeks of treatment, with placebo-corrected changes in peak VO2 at CPX after 24 weeks (or longest available follow up). Secondary exploratory endpoints will assess the effects of anakinra on additional CPX parameters, structural and functional echocardiographic data, noninvasive hemodynamic, quality of life questionnaires, biomarkers, and HF outcomes. Discussion The current trial will assess the effects of IL-1 blockade with anakinra for 24 weeks on cardiorespiratory fitness in patients with recent hospitalization due to acute decompensated HFrEF. Trial registration: The trial was registered prospectively with ClinicalTrials.gov on Jan 8, 2019, identifier NCT03797001.
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Affiliation(s)
- Benjamin Van Tassell
- Pauley Heart Center, Department of Internal Medicine, Virginia Commonwealth University, Pauley Heart Center, Richmond, VA, USA. .,Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA.
| | - Virginia Mihalick
- Pauley Heart Center, Department of Internal Medicine, Virginia Commonwealth University, Pauley Heart Center, Richmond, VA, USA
| | - Georgia Thomas
- Pauley Heart Center, Department of Internal Medicine, Virginia Commonwealth University, Pauley Heart Center, Richmond, VA, USA
| | - Amr Marawan
- Pauley Heart Center, Department of Internal Medicine, Virginia Commonwealth University, Pauley Heart Center, Richmond, VA, USA
| | - Azita H Talasaz
- Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Juan Lu
- Division of Epidemiology, Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, VA, USA
| | - Le Kang
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - Amy Ladd
- Pauley Heart Center, Department of Internal Medicine, Virginia Commonwealth University, Pauley Heart Center, Richmond, VA, USA
| | - Juan Ignacio Damonte
- Pauley Heart Center, Department of Internal Medicine, Virginia Commonwealth University, Pauley Heart Center, Richmond, VA, USA
| | - Dave L Dixon
- Pauley Heart Center, Department of Internal Medicine, Virginia Commonwealth University, Pauley Heart Center, Richmond, VA, USA.,Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Roshanak Markley
- Pauley Heart Center, Department of Internal Medicine, Virginia Commonwealth University, Pauley Heart Center, Richmond, VA, USA
| | - Jeremy Turlington
- Pauley Heart Center, Department of Internal Medicine, Virginia Commonwealth University, Pauley Heart Center, Richmond, VA, USA
| | - Emily Federmann
- Pauley Heart Center, Department of Internal Medicine, Virginia Commonwealth University, Pauley Heart Center, Richmond, VA, USA
| | - Marco Giuseppe Del Buono
- Pauley Heart Center, Department of Internal Medicine, Virginia Commonwealth University, Pauley Heart Center, Richmond, VA, USA
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.,Mediterranea Cardiocentro, Naples, Italy
| | - Justin M Canada
- Pauley Heart Center, Department of Internal Medicine, Virginia Commonwealth University, Pauley Heart Center, Richmond, VA, USA
| | - Ross Arena
- Department of Physical Therapy, College of Applied Science, University of Illinois Chicago, Chicago, IL, USA
| | - Antonio Abbate
- Pauley Heart Center, Department of Internal Medicine, Virginia Commonwealth University, Pauley Heart Center, Richmond, VA, USA
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12
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Reding K, O'Connell NS, Cheng R, Nguyen J, Ladd A, Jordan J, Ky B, Vasbinder A, Zaha V, Lucas A, Calhoun T, Hackney MH, Bellissimo M, D'Agostino R, Lesser GJ, Hundley WG. LVEF decline in relation to body composition among women treated for breast cancer: WF-97415. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.10556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10556 Background: Despite an improvement in survival from breast cancer (BC), many women experience cardiotoxicity. Left ventricular ejection fraction (LVEF) is reduced by an average of 9.7% in women receiving anthracyclines. Obesity and central adiposity at BC diagnosis may influence risk of LVEF decline. We sought to examine associations between body composition and LVEF decline in the UPBEAT (Understanding and Predicting Fatigue, Cardiovascular Decline, and Events After Breast Cancer: WF-97415) study, which was conducted in collaboration with NCI Community Oncology Research Program. Methods: The analytic cohort was comprised of 167 women treated for stage I-III BC with chemotherapy and/or radiation in the UPBEAT prospective study, in whom LVEF was obtained at baseline (pre-treatment) and 3 months. Linear regression was used to examine LVEF decline in relation to 1) waist circumference (WC) and body mass index (BMI) at baseline and 2) changes in WC and BMI during BC treatment. All models were adjusted for age and race. Results: In this cohort (mean [SD] age: 55.7 [10.8] yrs; in whom 75% were white; 19% were Black), the mean (SD) LVEF at baseline was 60.7 (6.7)% with a mean decline of 2.7 (7.2)% from baseline to 3-months. Both WC and BMI at BC diagnosis were associated with LVEF decline during follow-up (Table). For each additional inch in WC, EF decreased by 0.25% points at 3 months (P=0.024); for each additional kg/m2 in BMI, EF decreased by 0.2% points at 3 months (P=0.007). Reduced BMI during treatment was associated with LVEF decline, whereas a change in WC was not. Each kg/m2 reduction in BMI was associated with a 0.4% point decrease in LVEF (p=0.037). Anthracycline use was associated with a 1.89% point decline in LVEF at 3 months versus non-users (p=0.049). After additional adjustment for anthracycline use, baseline WC remained statistically significantly associated with LVEF decline to the same degree. Conclusions: These data show that central adiposity at BC diagnosis is associated with LVEF decline during treatment, even after controlling for anthracyclines. Loss of central adiposity was not associated with LVEF decline, whereas BMI loss during treatment was. This suggests that shifts in body composition during BC treatment, potentially via loss of muscle mass, are important to monitor in patients. Future work should examine how changes in body composition, particularly changes in skeletal muscle and adipose tissue depots, influence cardiac dysfunction in BC patients during treatment. Funding: 2UG1CA189824, R01CA199167, 2UG1CA189828. [Table: see text]
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Affiliation(s)
| | | | | | | | - Amy Ladd
- Virginia Commonwealth University, Richmond, VA
| | | | - Bonnie Ky
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | - Vlad Zaha
- University of Texas Southwestern Medical Center, Dallas, TX
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13
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Hundley WG, D'Agostino R, Crotts T, Hackney MH, Jordan J, Ky B, Wagner LI, Herrington D, Yeboah J, Reding K, Ladd A, Rapp S, Russo S, O'Connell NS, Weaver KE, Dressler EVM, Ge Y, Melin SA, Gudena VK, Lesser GJ. Randomized trial of atorvastatin during and following receipt of doxorubicin for breast cancer and lymphoma (WF-98213). J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.12072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
12072 Background: Statins taken for cardiovascular (CV) indications by breast cancer (BC) and lymphoma survivors during doxorubicin (DOX) treatment may attenuate left ventricular ejection fraction (LVEF) decline, but statin impact among these survivors with no CV indications is unknown. Methods: In 279 patients from 31 cancer centers, we conducted a double blind, placebo-controlled, 24-month randomized trial of 40mg/day atorvastatin among those receiving DOX for BC or lymphoma. At pretreatment, six and 24 months after initiating DOX for BC or lymphoma, we assessed LV volumes, strain, mass, and LVEF (via cardiac magnetic resonance), cognitive function and serum markers of inflammation. Using a linear model adjusted for pretreatment measures, our primary analysis assessed change in LVEF over time by randomization group. Results: Participants were aged 49±12 years; 92% women, 83% white race. The mean pooled LVEF decline from pretreatment to 24 months was 62.2±6.0% to 57.6±6.3% (p < 0.001). Adjusting for pretreatment LVEF, 24-month declines in LVEF averaged 3.5±0.5% and 3.3±0.5% respectively for placebo vs statins (p = 0.83). Both randomized groups were similar for: incidence of > 10% change in LVEF, LV strain, LV mass, cognition and inflammation biomarkers, including among those > 90% study drug compliant (p > 0.05 for all). Conclusions: In BC and lymphoma survivors with no existing indication for statin therapy, prospective statin administration does not appear to impact LVEF declines two years after doxorubicin. Clinical trial information: NCT01988571. [Table: see text]
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Affiliation(s)
| | | | | | | | | | - Bonnie Ky
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | | | | | | | - Amy Ladd
- Virginia Commonwealth University, Richmond, VA
| | - Steve Rapp
- Wake Forest University, School of Medicine, Winston Salem, NC
| | | | | | | | | | - Yaorong Ge
- University of North Carolina at Charlotte, Charlotte, NC
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14
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Avis NE, Levine BJ, Mihalko SL, Klepin HD, Brubaker PH, Calhoun T, Dent SF, Hackney MH, Ky B, Ladd A, Ntim WO, Wagner LI, Weaver KE, Hundley WG. The impact of anthracycline-based chemotherapy on fatigue: Results from WF-97415. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e24115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e24115 Background: Chemotherapy (CT) is one of the most common factors associated with fatigue among breast cancer (BC) patients. However, there is a paucity of research on the impact of different types of CT on fatigue, specifically, whether women who receive anthracycline-based (Anth) CT experience greater fatigue than those who receive non-anthracycline-based (noAnth) CT. Methods: Analyses are from the longitudinal Understanding and Predicting fatigue, cardiovascular decline, and events after BrEast cAncer sTudy (UPBEAT: WF 97415)), conducted through the NCI Community Oncology Research Program (NCORP). We compared fatigue 3-months after initiating cancer treatment, controlling for fatigue measured just prior to beginning CT (baseline), in 3 groups of women: BC patients receiving Anth CT (N = 103 at baseline), BC patients receiving NoAnth CT (N = 155), and women without cancer (N = 145). Fatigue was measured by the Functional Assessment of Chronic Illness Therapy Fatigue scale where lower scores indicate greater fatigue. Scores < 30 indicate severe fatigue. We used ANOVA and ANCOVA models (PROC GLM; SAS v. 9.4) to generate unadjusted and adjusted mean fatigue scores in the 3 groups at the relevant time point. Given that selection to CT type was not random, we further adjusted for patient characteristics that influence treatment type (stage and comorbidities) in a model with the two CT groups only. Results: Mean age of participants (75.7% White and 18.1% Black) was 53.9 years. Among BC patients, the Anth group had higher tumor stage compared to the NoAnth group. Both cancer treatment groups reported significantly greater (unadjusted) fatigue pre-chemotherapy and at 3 months than healthy controls, but did not differ from each other. Adjusting for age and baseline fatigue, 3-month fatigue scores were significantly worse for the two CT groups (32.3 for Anth group, 34.3 for the NoAnth group) compared to the controls (44.6) (p < .0001). In a model of cancer patients only, the difference between Anth and NoAnth groups remained non-significant (p = 0.10), after adjusting additionally for number of comorbidities and cancer stage. The unadjusted percentage of women with severe fatigue at 3 months was significantly greater for the BC patients (39% in the Anth group; 38% in the NoAnth group) compared to the healthy controls (1%), but again the two chemotherapy groups were not significantly different from each other. Adjustment for covariates listed above did not change this finding. Conclusions: Analyses support previous studies showing significant fatigue among BC patients treated with CT compared to women without cancer. Our data suggest that fatigue significantly impacts patients receiving CT irrespective of the regimen selected.[Table: see text]
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Affiliation(s)
- Nancy E Avis
- Wake Forest School of Medicine, Winston Salem, NC
| | | | | | - Heidi D. Klepin
- Wake Forest Baptist Comprehensive Cancer Center, Winston Salem, NC
| | | | | | | | | | - Bonnie Ky
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Amy Ladd
- Virginia Commonwealth University, Richmond, VA
| | - William Ofori Ntim
- UNC School of Medicine, Novant Health Campus, Novant Health Heart & Vascular Institute, Charlotte, NC
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15
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Shyamsunder S, D'Agostino R, O'Connell NS, Ladd A, Weaver KE, Lesser GJ, Hundley WG, Hackney MH, Melin SA, Ge Y. Machine learning models for accurate pretreatment prediction of chemotherapy associated LV dysfunction in patients with breast cancer and lymphoma receiving chemotherapy (WF-98213 PREVENT and CCCWFU9912 DETECT IV). J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.1553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
1553 Background: Cancer survivors receiving potentially cardiotoxic chemotherapy are at increased risk for developing left ventricular (LV) dysfunction. We implemented machine learning (ML) models to predict future LV dysfunction in patients with breast cancer or lymphoma scheduled to receive potentially cardiotoxic chemotherapy. Methods: We utilized prospectively collected data from NIH studies R01HL118740 (supported by the Wake Forest NCORP Research Base (UG1CA189824)) and R01CA167821. Data included measurements of LV function and demographic factors before, during, and 24 months after initiating potentially cardiotoxic chemotherapy. The two datasets were used both separately and collectively in the development of multiple ML models including penalized linear regression, support vector machine, and random forest (RF). A data preprocessing step properly handled missing information, data imbalance, and encoding. Hyperparameter tuning was performed using cross validation of training data. The final models were assessed with a 20% hold-out test dataset. Cardiotoxicity was defined as a pre- to 24-month post cancer treatment decline in LV ejection fraction (LVEF) of > 10% or to an absolute value of < 50%. Results: 276 patients were included in ML models (7% men, 93% women; age 52±13 years). The RF model based on the combined dataset had the best performance with a prediction accuracy, sensitivity, and specificity of 0.94, 0.81, and 0.98, respectively. The most important variables assessed pre-treatment as measured by the Gini impurity factor were in descending order, LVEF, global LV circumferential strain, LV end-systolic volume, body mass index, LV stroke volume, LV end-diastolic volume, and LV mass. Conclusions: Prior to cancer treatment, supervised ML methods such as RF models predicted declines in LVEF of > 10% and/or to absolute values below 50% would occur 24 months after initiating chemotherapy for breast cancer or lymphoma. With further improvement and validation using larger datasets, these models may play an important role in cardio-oncology care during and following cancer treatment.
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Affiliation(s)
| | | | | | - Amy Ladd
- Virginia Commonwealth University, Richmond, VA
| | | | | | | | | | | | - Yaorong Ge
- University of North Carolina at Charlotte, Charlotte, NC
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16
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Heiston EM, Mabudian L, O'Connell NS, D'Agostino R, Brubaker PH, Mihalko SL, Reding K, Bellissimo M, Ladd A, Lucas A, Jordan J, Ky B, Calhoun T, Hackney MH, Weaver KE, Lesser GJ, Hundley WG. Impact of cardiometabolic health and abdominal adipose tissue on physical function in women with breast cancer (WF-97415). J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e18696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e18696 Background: Breast cancer treatments often result in a decline in physical function that may be worsened by high levels of abdominal adipose tissue (AAT). However, the role of cardiometabolic health, which is comprised of interrelated risk factors of insulin resistance, dyslipidemia, hypertension, and central adiposity, has been infrequently addressed. Thus, we evaluated the relationship between physical function and cardiometabolic health controlling for AAT in women with breast cancer before and during receipt of potentially cardiotoxic chemotherapy. Methods: Women recruited through NCORP with stage I-III breast cancer completed a six-minute walk distance (6MWD) test to determine physical function, magnetic resonance imaging (MRI) to evaluate AAT, and assessments of cardiometabolic health before and following 3 months of chemotherapy. Specifically, MRI was used to measure waist circumference (WC), and AAT components of subcutaneous (SAT) and visceral adipose tissue (VAT). To assess cardiometabolic health, individual metabolic syndrome (MetS) components of WC, mean arterial pressure (MAP), glucose (FPG), high-density lipoprotein cholesterol (HDL), and triglycerides (TG) were used to calculate a MetS severity z-score (MetS-Z) = [(WC-88)/SD] + [(MAP-100)/SD] + [(FPG-100)/SD] + [(50-HDL)/SD] + [(TG-150)/SD]. All measures were assessed by individuals blinded to visit, demographic data, and other components of the study. Baseline and 3-month data were compared via paired t-tests. Regression analyses were used to identify the relationship between 6MWD and MetS-Z and possible mediation effects of AAT (i.e., SAT and VAT). Results: One hundred eleven women with a mean age of 56.1 ± 11.0 yrs completed assessments. After 3 months of chemotherapy, 6MWD was lower (457 ± 90.7 vs 428 ± 92.9 m, P= 0.001) and MetS-Z was increased (-1.13 ± 3.01 vs 0.30 ± 3.97 AU, P< 0.001) compared to baseline. The increase in MetS-Z was mainly attributed to elevations in TG (120 ± 81 vs 154 ± 111 mg/dl, P< 0.001) and decreases in HDL (58.6 ± 14.3 vs 47.7 ± 13.9 mg/dl, P< 0.001). No changes were observed in SAT ( P= 0.15) or VAT ( P= 0.42). Although MetS-Z was associated with 6MWD at baseline ( P= 0.01), MetS-Z was not significant predictor after controlling for SAT and VAT (B = -3.39, P= 0.34, 95% CI [-10.4, 3.62]). MetS-Z also associated wtih 6MWD at 3 months ( P= 0.002) and this remained significant after controlling for SAT and VAT (B = -5.36, P= 0.03, 95% CI [-10.3, -0.46]). Conclusions: AAT may be more strongly associated with physical function prior to chemotherapy whereas cardiometabolic traits may have clinical implications during treatment in women with breast cancer. Additional longitudinal work investigating the effects of concurrent treatments (e.g., exercise, diet, pharmacological) on the relationship between cardiometabolic health and physical function is warranted. Clinical trial information: NCT02791581.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Amy Ladd
- Virginia Commonwealth University, Richmond, VA
| | | | | | - Bonnie Ky
- Hospital of the University of Pennsylvania, Philadelphia, PA
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Suddala S, O'Connell NS, D'Agostino RB, Jordan JH, Meléndez GC, Hackney MH, Ladd A, Miller D, Lesser GJ, Weaver KE, Lucas AR, Thomas A, Hundley WG. PRIOR TO CANCER TREATMENT, DO WOMEN WITH BREAST CANCER EXPERIENCE REDUCED AORTIC DISTENSIBILITY IN THE ABSENCE OF HYPERTENSION? J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)02874-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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18
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Kron J, Crawford T, Mihalick V, Bogun F, Jordan JH, Koelling T, Syed H, Syed A, Iden T, Polly K, Federmann E, Bray K, Lathkar-Pradhan S, Jasti S, Rosenfeld L, Birnie D, Smallfield M, Kang L, Fowler AB, Ladd A, Ellenbogen K, Van Tassell B, Gregory Hundley W, Abbate A. Interleukin-1 blockade in cardiac sarcoidosis: study design of the multimodality assessment of granulomas in cardiac sarcoidosis: Anakinra Randomized Trial (MAGiC-ART). J Transl Med 2021; 19:460. [PMID: 34749739 PMCID: PMC8575149 DOI: 10.1186/s12967-021-03130-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 10/23/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Sarcoidosis is an inflammatory disease characterized by the formation of granulomas, which involve the heart in up to 25% of patients. Cardiac sarcoidosis can lead to life threatening arrhythmias and heart failure. While corticosteroids have been used as a treatment for over 50 years, they are associated with hypertension, diabetes, and weight gain, further increasing cardiovascular risk. Interleukin-1 (IL-1) is the prototypical proinflammatory cytokine that works to activate the nuclear transcription factor NF-kB, one of the targets of glucocorticoids. IL-1 also plays an important role also in the pathophysiology of heart disease including atherosclerosis, myocardial infarction, and myocarditis. METHODS Building on a network of research collaborators developed in the Cardiac Sarcoidosis Consortium, we will investigate the feasibility and tolerability of treatment of CS with anakinra at two National Institute of Health Clinical and Translational Science Award (CTSA) hubs with expertise in cardiac sarcoidosis. In this pilot study, up to 28 patients with cardiac sarcoidosis will be recruited to compare the administration of an IL-1 blocker, anakinra, 100 mg daily on top of standard of care versus standard of care only for 28 days and followed for 180 days. Utilizing surrogate endpoints of changes in systemic inflammatory biomarkers and cardiac imaging, we aim to determine whether IL-1 blockade with anakinra can combat systemic and cardiac inflammation in patients with cardiac sarcoidosis. DISCUSSION The current trial demonstrates an innovative collaborative approach to clinical trial development in a rare, understudied disease that disproportionately affects females and minorities. Trial Registration The trial was registered prospectively with ClinicalTrials.gov on July 12, 2019, identifier NCT04017936.
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Affiliation(s)
- Jordana Kron
- VCU Pauley Heart Center, Virginia Commonwealth University, Virginia Commonwealth University Medical Center, P.O. Box 980053, Richmond, VA, 23298-0053, USA.
| | - Thomas Crawford
- Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Virginia Mihalick
- VCU Pauley Heart Center, Virginia Commonwealth University, Virginia Commonwealth University Medical Center, P.O. Box 980053, Richmond, VA, 23298-0053, USA
| | - Frank Bogun
- Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Jennifer H Jordan
- VCU Pauley Heart Center, Virginia Commonwealth University, Virginia Commonwealth University Medical Center, P.O. Box 980053, Richmond, VA, 23298-0053, USA.,Department of Biomedical Engineering, Virginia Commonwealth University, Richmond, VA, USA
| | - Todd Koelling
- Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Huzaefah Syed
- Division of Rheumatology, Virginia Commonwealth University, Allergy, and Immunology, Richmond, VA, USA
| | - Aamer Syed
- Division of Pulmonary and Critical Care, Virginia Commonwealth University, Richmond, VA, USA
| | - Thomas Iden
- Division of Pulmonary and Critical Care, Virginia Commonwealth University, Richmond, VA, USA
| | - Kelly Polly
- Division of Pulmonary and Critical Care, Virginia Commonwealth University, Richmond, VA, USA
| | - Emily Federmann
- VCU Pauley Heart Center, Virginia Commonwealth University, Virginia Commonwealth University Medical Center, P.O. Box 980053, Richmond, VA, 23298-0053, USA
| | - Kirsta Bray
- Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | | | - Shilpa Jasti
- VCU Pauley Heart Center, Virginia Commonwealth University, Virginia Commonwealth University Medical Center, P.O. Box 980053, Richmond, VA, 23298-0053, USA
| | - Lynda Rosenfeld
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - David Birnie
- University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Melissa Smallfield
- VCU Pauley Heart Center, Virginia Commonwealth University, Virginia Commonwealth University Medical Center, P.O. Box 980053, Richmond, VA, 23298-0053, USA
| | - Le Kang
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - Alpha Berry Fowler
- Division of Pulmonary and Critical Care, Virginia Commonwealth University, Richmond, VA, USA
| | - Amy Ladd
- VCU Pauley Heart Center, Virginia Commonwealth University, Virginia Commonwealth University Medical Center, P.O. Box 980053, Richmond, VA, 23298-0053, USA
| | - Kenneth Ellenbogen
- VCU Pauley Heart Center, Virginia Commonwealth University, Virginia Commonwealth University Medical Center, P.O. Box 980053, Richmond, VA, 23298-0053, USA
| | - Benjamin Van Tassell
- VCU Pauley Heart Center, Virginia Commonwealth University, Virginia Commonwealth University Medical Center, P.O. Box 980053, Richmond, VA, 23298-0053, USA.,Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
| | - W Gregory Hundley
- VCU Pauley Heart Center, Virginia Commonwealth University, Virginia Commonwealth University Medical Center, P.O. Box 980053, Richmond, VA, 23298-0053, USA
| | - Antonio Abbate
- VCU Pauley Heart Center, Virginia Commonwealth University, Virginia Commonwealth University Medical Center, P.O. Box 980053, Richmond, VA, 23298-0053, USA.,Kenneth and Dianne Wright Center for Clinical and Translational Research, Virginia Commonwealth University, Richmond, VA, USA
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19
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Ladd A, Klaczkiewicz K, Gills S, Duru B. Standardization of Bulk Formula Recipes to Improve Safety in a Pediatric Hospital. J Acad Nutr Diet 2021. [DOI: 10.1016/j.jand.2021.06.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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20
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Wang T, Xiong G, Lu L, Bernstein J, Ladd A. Musculoskeletal Education in Medical Schools: a Survey in California and Review of Literature. Med Sci Educ 2021; 31:131-136. [PMID: 34457873 PMCID: PMC8368391 DOI: 10.1007/s40670-020-01144-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/26/2020] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Though musculoskeletal complaints account for roughly one-quarter of primary care and emergency department visits, only 2% of US medical school curriculum is devoted to musculoskeletal disease. Many graduating students demonstrate poor knowledge and report low confidence in treating musculoskeletal disorders. This study defines the current state of musculoskeletal curriculum of medical schools in detail to identify variations and potential shortcomings. METHODS All eleven medical schools in California were invited to participate in an in-depth survey detailing the design and content of their musculoskeletal curriculum. RESULTS A response rate of 100% was achieved. Overall, schools devoted an average of 58.7 h to musculoskeletal medicine, of which more than half was spent covering anatomy. The primary instructor for musculoskeletal medicine was a clinician in four schools (36.4%). Six schools offered a dedicated musculoskeletal physical exam course. No schools required students to complete a clinical rotation in musculoskeletal medicine. There was high variability among institutions when evaluating core subject coverage. DISCUSSION There is large variation in the content and structure of musculoskeletal instruction among California medical schools. Increased curricular time, integration of preclinical and clinical experiences, greater specialist participation, and standardized objectives may provide more consistent and comprehensive musculoskeletal education. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s40670-020-01144-3.
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Affiliation(s)
- Tim Wang
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway St, Pavilion C, 4th Floor, Redwood City, CA 94063 USA
| | - Grace Xiong
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway St, Pavilion C, 4th Floor, Redwood City, CA 94063 USA
| | - Laura Lu
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway St, Pavilion C, 4th Floor, Redwood City, CA 94063 USA
| | - Joseph Bernstein
- University of Pennsylvania School of Medicine, Philadelphia, PA USA
| | - Amy Ladd
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway St, Pavilion C, 4th Floor, Redwood City, CA 94063 USA
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21
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Shapiro LM, McQuillan TJ, Kerkhof FD, Ladd A. Radiographic Progression of Thumb CMC Osteoarthritis: A Systematic Review. Journal of Hand Surgery Global Online 2020; 2:343-348. [PMID: 35415524 PMCID: PMC8991744 DOI: 10.1016/j.jhsg.2020.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 09/02/2020] [Indexed: 11/19/2022] Open
Affiliation(s)
- Lauren M. Shapiro
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
- Corresponding author: Lauren M. Shapiro, MD, Department of Orthopaedic Surgery, Stanford University, 450 Broadway Street, Redwood City, CA 94603.
| | | | - Faes D. Kerkhof
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
| | - Amy Ladd
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
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22
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Zhuang T, Shapiro LM, Ring D, Akelman E, Ruch DS, Richard MJ, Ladd A, Blazar P, Yao J, Kakar S, Harris AHS, Got C, Kamal RN. Which Decisions For Management of Carpal Tunnel Syndrome and Distal Radius Fractures Should Be Shared? J Hand Surg Am 2020; 45:690-697.e7. [PMID: 32340760 DOI: 10.1016/j.jhsa.2020.03.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 02/11/2020] [Accepted: 03/11/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate, from the surgeon's perspective, the importance, feasibility, and appropriateness of sharing decisions during an episode of care of carpal tunnel syndrome (CTS) or distal radius fracture in patients aged greater than 65 years. METHODS A consortium of 9 fellowship-trained hand/upper-limb surgeons used the RAND Corporation/University of California Los Angeles Delphi Appropriateness method to evaluate the importance, feasibility, and appropriateness of sharing 27 decisions for CTS and 28 decisions for distal radius fractures in patients aged greater than 65 years. Panelists rated each measure on a scale of 1 (definitely not important/feasible/appropriate) to 9 (definitely important/feasible/appropriate) in 2 voting rounds with an intervening face-to-face discussion. Panelist agreement and disagreement were assessed using predetermined criteria. RESULTS Panelists achieved agreement on 16 decisions (29%) as important, 43 (78%) as feasible, and 17 (31%) as appropriate for sharing with patients. Twelve decisions met all 3 of these criteria and were therefore considered important, feasible, and appropriate to share with patients. Examples in CTS included decisions to perform extra confirmatory diagnostic testing, to have surgery, and to perform a steroid injection into the carpal tunnel. Examples in distal radius fracture management included the decision to have surgery, type of pain medication prescribed after surgery, and whether to remove the implant. The remaining 43 decisions did not reach consensus on the importance, feasibility, and appropriateness of sharing with patients. CONCLUSIONS Using a validated consensus-building approach, we identified 12 decisions made during an episode of care for CTS or distal radius fracture that were important, feasible, and appropriate to share with patients from the surgeon's perspective. These decisions merit inclusion in shared decision-making models (eg, preoperative patient preference elicitation tools or decision aids) to align patient preferences with care decisions. CLINICAL RELEVANCE Understanding which aspects of care are important, feasible, and appropriate to share with patients may improve patient-centered care by aligning patient preferences with care decisions.
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Shapiro LM, Ring D, Akelman E, Ruch, Richard MJ, Ladd A, Blazar P, Yao J, Kakar S, Harris AH, Got C, Kamal RN. Quality Measures to Reduce Opioid Use After Common Soft Tissue Hand and Wrist Procedures. J Hand Surg Am 2020; 45:582-588.e4. [PMID: 32408999 DOI: 10.1016/j.jhsa.2020.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 11/03/2019] [Accepted: 03/03/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To develop quality measures that are clinically important, feasible, usable, and scientifically acceptable for reducing opioid use after soft tissue procedures of the hand and wrist, and which can be used to evaluate quality in hand surgery. METHODS A consortium of 9 fellowship-trained hand/upper-limb surgeons with expertise in quality measure development used the RAND Corporation/University of California Los Angeles Delphi Appropriateness method to evaluate the validity of 2 quality measures for reducing opioid use, based on 4 quality indicators (clinical importance, feasibility, usability, and scientific acceptability). Panelists rated each measure on a scale of 1 (definitely not important/feasible/usable/supported) to 9 (definitely important/feasible/usable/supported) in 2 voting rounds with an intervening face-to-face discussion. Agreement was assessed using predetermined criteria. A measure was considered a valid quality measure if it received a median score of 7 or higher for all 4 indicators with no more than 2 panelists rating outside the range of 7 to 9. RESULTS Panelists achieved agreement on the 4 quality indicators for measuring the proportion of patients undergoing carpal tunnel release, trigger finger release, first dorsal compartment release, or ganglion cyst excision who received structured counseling on opioid use. Panelists also achieved agreement on the 4 quality indicators for measuring the proportion of patients without recent opioid use who did not fill an opioid prescription within 30 days after these procedures. Both candidate quality measures were considered valid. CONCLUSIONS Using a validated consensus-building approach, we developed process and outcome quality measures for reducing opioid use after soft tissue hand surgery that were demonstrated to be valid according to 4 quality indicators. CLINICAL RELEVANCE In the era of value-based health care, hand surgeons are assuming increasing responsibility in the prevention of excess opioid prescribing. Quality measures for reducing opioid overprescription can help promote the delivery of evidence-based, high-quality care in hand surgery.
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Abstract
Dorsoradial and anterior oblique ligaments were harvested during surgery in 13 patients with symptomatic trapeziometacarpal osteoarthritis, which had been graded preoperatively by a modified Eaton-Littler radiographic grading. Ligaments, including the periligamentous synovium, were stained with S100 protein, neurotrophic receptor p75, protein gene product 9.5, calcitonin gene related peptide, acetylcholine, substance P, neuropeptide Y, noradrenaline, N-methyl-D-aspartate-receptor and Met/Leu-enkephalin. The synovium was classified as showing no, low-grade or high-grade synovitis. Free nerve endings had higher immunoreactivity for substance P than for N-methyl-D-aspartate-receptor, enkephalin and noradrenaline. The synovial stroma had less immunoreactivity for N-methyl-D-aspartate-receptor than for noradrenaline, substance P and calcitonin gene related peptide. There was no relation between the grade of osteoarthritis and the visual pain analogue scale, synovitis score, immunoreactivity of all antibodies and quantity of free nerve endings or blood vessels. Synovium in trapeziometacarpal joint osteoarthritis produces several neuromediators causing a polymodal neurogenic inflammation and which may serve as biomarkers for osteoarthritis or therapeutic targets.
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Affiliation(s)
- Susanne Rein
- Department of Plastic and Hand Surgery, Burn Unit, Hospital Sankt Georg, Leipzig, Germany
| | - Janet Okogbaa
- Department of Orthopaedic Surgery, Chase Hand Center, Stanford University, Stanford, CA, USA
| | - Elisabet Hagert
- Department of Clinical Science and Education, Karolinska Institutet, Arcademy, H. M. Queen Sophia Hospital, Stockholm, Sweden
| | - Suzanne Manthey
- University Center of Orthopaedics and Traumatology, University Medicine Carl Gustav Carus Dresden, Technical University Dresden, Dresden, Germany
| | - Amy Ladd
- Department of Orthopaedic Surgery, Chase Hand Center, Stanford University, Stanford, CA, USA
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Mathurin S, Fay M, Archuleta S, Ladd A. Clinical Nutrition Staffing and Oversight of Formula Lab Operations Ensures Full Compliance with National Guidelines and Standards While Decreasing Formula Lab Related Errors. J Acad Nutr Diet 2018. [DOI: 10.1016/j.jand.2018.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Akelman E, Ruch DS, Richard MJ, Ladd A, Got C, Blazar P, Yao J, Kakar S, Harris AH, Ring D. Candidate Quality Measures for Hand Surgery. J Hand Surg Am 2017; 42:859-866.e3. [PMID: 28818350 DOI: 10.1016/j.jhsa.2017.07.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 06/16/2017] [Accepted: 07/10/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE Quality measures are tools used by physicians, health care systems, and payers to evaluate performance, monitor the outcomes of interventions, and inform quality improvement efforts. A paucity of quality measures exist that address hand surgery care. We completed a RAND/UCLA (University of California Los Angeles) Delphi Appropriateness process with the goal of developing and evaluating candidate hand surgery quality measures to be used for national quality measure development efforts. METHODS A consortium of 9 academic upper limb surgeons completed a RAND/UCLA Delphi Appropriateness process to evaluate the importance, scientific acceptability, usability, and feasibility of 44 candidate quality measures. These addressed hand problems the panelists felt were most appropriate for quality measure development. Panelists rated the measures on an ordinal scale between 1 (definitely not valid) and 9 (definitely valid) in 2 rounds (preliminary round and final round) with an intervening face-to-face discussion. Ratings from 1 to 3 were considered not valid, 4 to 6 as equivocal or uncertain, and 7 to 9 as valid. If no more than 2 of the 9 ratings were outside the 3-point range that included the median (1-3, 4-6, or 7-9), the panelists were considered to be in agreement. If 3 or more of the panelists' ratings of a measure were within the 1 to 3 range and 3 or more ratings were in the 7 to 9 range, the panelists were considered to be in disagreement. RESULTS There was agreement on 43% (19) of the measures as important, 27% (12) as scientifically sound, 48% (21) as usable, and 59% (26) as feasible to complete. Ten measures met all 4 of these criteria and were, therefore, considered valid measurements of quality. Quality measures that were developed address outcomes (patient-reported outcomes for assessment and improvement of function) and processes of care (utilization rates of imaging, antibiotics, occupational therapy, ultrasound, and operative treatment). CONCLUSIONS The consortium developed 10 measures of hand surgery quality using a validated methodology. These measures merit further development. CLINICAL RELEVANCE Quality measures can be used to evaluate the quality of care provided by physicians and health systems and can inform quality and value-based reimbursement models.
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McQuillan T, Wilcox-Fogel N, Kraus E, Ladd A, Fredericson M. Integrating Musculoskeletal Education and Patient Care at Medical Student-Run Free Clinics. PM R 2017; 9:1117-1121. [PMID: 28389399 DOI: 10.1016/j.pmrj.2017.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 03/11/2017] [Accepted: 03/22/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Student-run free clinics (SRFCs) have emerged as an important educational component of United States (U.S.) medical schools. Despite the prevalence of musculoskeletal (MSK) problems presenting to SRFCs, students and clinics are often unprepared to diagnose and to treat common MSK complaints. OBJECTIVE We sought to determine the scope of diagnosis and treatment at a medical student-run free clinic specializing in musculoskeletal care using physical medicine and rehabilitation (PM&R) residents. Secondary goals included reviewing student satisfaction and determining the appropriateness of the clinic in medical education. DESIGN Retrospective chart review, anonymous online survey. SETTING Primary care, free student clinic affiliated with tertiary academic medical center. PARTICIPANTS A total of 20 medical student volunteers, 6 PM&R residents, and 91 community patients. METHODS We established a musculoskeletal clinic as a specialty referral clinic for the 2 primary care SRFCs with institutional support from a partner medical school. We then reviewed clinical operations retrospectively using electronic medical records and student satisfaction based on an online survey. MAIN OUTCOME MEASUREMENTS We analyzed patient demographics and chief complaints, referrals provided, and medical services rendered. We also used a 5-point Likert scale to assess student satisfaction. RESULTS A monthly musculoskeletal referral clinic was established with the oversight of PM&R attendings and residents. The clinic received 91 referrals and managed 61 unique patients over a 2.5-year study period. The most common presentations to the clinic involved knee pain (n = 17, 27.9%) and back pain (n = 16, 26.2%). Pro bono relationships with community and institutional partners enabled all patients to receive medical examinations, physical therapy visits, plain film radiographs, and insurance consultations free of charge. Student satisfaction with teaching and patient care was high, with 19 of 20 students reporting their experience as "good" or "excellent." CONCLUSIONS SRFCs represent an underused opportunity to enhance MSK education among medical students by treating a variety of common MSK complaints in an underserved population. LEVEL OF EVIDENCE Not applicable.
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Affiliation(s)
- Thomas McQuillan
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway St, Redwood City, CA 94063(∗).
| | - Nate Wilcox-Fogel
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA(†)
| | - Emily Kraus
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA(‡)
| | - Amy Ladd
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA(§)
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Lattanza LL, Meszaros-Dearolf L, O’Connor MI, Ladd A, Bucha A, Trauth-Nare A, Buckley JM. The Perry Initiative's Medical Student Outreach Program Recruits Women Into Orthopaedic Residency. Clin Orthop Relat Res 2016; 474:1962-6. [PMID: 27245771 PMCID: PMC4965379 DOI: 10.1007/s11999-016-4908-y] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Orthopaedic surgery lags behind other surgical specialties in terms of gender diversity. The percentage of women entering orthopaedic residency persistently remains at 14% despite near equal ratios of women to men in medical school classes. This trend has been attributed to negative perceptions among women medical students of workplace culture and lifestyle in orthopaedics as well as lack of exposure, particularly during medical school when most women decide to enter the field. Since 2012, The Perry Initiative, a nonprofit organization that is focused on recruiting and retaining women in orthopaedics, had conducted extracurricular outreach programs for first- and second-year female medical students to provide exposure and mentoring opportunities specific to orthopaedics. This program, called the Medical Student Outreach Program (MSOP), is ongoing at medical centers nationwide and has reached over 300 medical students in its first 3 program years (2012-2014). QUESTIONS/PURPOSES (1) What percentage of MSOP participants eventually match into orthopaedic surgery residency? (2) Does MSOP impact participants' perceptions of the orthopaedics profession as well as intellectual interest in the field? METHODS The percentage of program alumnae who matched into orthopaedics was determined by annual followup for our first two cohorts who graduated from medical school. All program participants completed a survey immediately before and after the program that assessed the impact of MSOP on the student's intention to pursue orthopaedics as well as perceptions of the field and intellectual interest in the discipline. RESULTS The orthopaedic surgery match rate for program participants was 31% in our first graduating class (five of 16 participants in 2015) and 28% in our second class (20 of 72 participants in 2016). Pre/post program comparisons showed that the MSOP influenced students' perceptions of the orthopaedics profession as well as overall intellectual interest in the field. CONCLUSIONS The results of our study suggest that The Perry Initiative's MSOP positively influences women to choose orthopaedic surgery as a profession. The match rate for program alumnae is twice the percentage of females in current orthopaedic residency classes. Given these positive results, MSOP can serve as a model, both in its curricular content and logistic framework, for other diversity initiatives in the field.
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Affiliation(s)
- Lisa L. Lattanza
- The Perry Initiative, Newark, DE USA ,Department of Orthopaedic Surgery, University of California San Francisco, 1500 Owens Street, Suite 170, San Francisco, CA 94158 USA
| | | | - Mary I. O’Connor
- The Perry Initiative, Newark, DE USA ,Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT USA
| | - Amy Ladd
- The Perry Initiative, Newark, DE USA ,Department of Orthopaedic Surgery, Stanford University, Palo Alto, CA USA
| | - Amy Bucha
- The Perry Initiative, Newark, DE USA
| | - Amy Trauth-Nare
- College of Education & Human Development, University of Delaware, Newark, DE USA
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Kamal RN, Kakar S, Ruch D, Richard MJ, Akelman E, Got C, Blazar P, Ladd A, Yao J, Ring D. Quality Measurement: A Primer for Hand Surgeons. J Hand Surg Am 2016; 41:645-51. [PMID: 26576831 DOI: 10.1016/j.jhsa.2015.10.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Revised: 09/26/2015] [Accepted: 10/01/2015] [Indexed: 02/02/2023]
Abstract
As the government and payers place increasing emphasis on measuring and reporting quality and meeting-specific benchmarks, physicians and health care systems will continue to adapt to meet regulatory requirements. Hand surgeons' involvement in quality measure development will help ensure that our services are appropriately assessed. Moreover, by embracing a culture of quality assessment and improvement, we will improve patient care while demonstrating the importance of our services in a health care system that is transitioning from a fee-for-service model to a fee-for-value model. Understanding quality and the tools for its measurement, and the application of quality assessment and improvement methods can help hand surgeons continue to deliver high-quality care that aligns with national priorities.
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Affiliation(s)
- Robin N Kamal
- Hand Surgery Quality Consortium (HSQC); Department of Orthopaedic Surgery, Stanford University, Redwood City, CA.
| | - Sanjeev Kakar
- Hand Surgery Quality Consortium (HSQC); Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN
| | - David Ruch
- Hand Surgery Quality Consortium (HSQC); Department of Orthopaedic Surgery, Duke University, Durham, NC
| | - Marc J Richard
- Hand Surgery Quality Consortium (HSQC); Department of Orthopaedic Surgery, Duke University, Durham, NC
| | - Edward Akelman
- Hand Surgery Quality Consortium (HSQC); Department of Orthopaedic Surgery, Rhode Island Hospital/Brown University, Providence, RI
| | - Chris Got
- Hand Surgery Quality Consortium (HSQC); Department of Orthopaedic Surgery, Rhode Island Hospital/Brown University, Providence, RI
| | - Philip Blazar
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA; Department of Orthopaedic Surgery, Brigham and Women's Hospital/Harvard University, Boston, MA
| | - Amy Ladd
- Hand Surgery Quality Consortium (HSQC); Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
| | - Jeffrey Yao
- Hand Surgery Quality Consortium (HSQC); Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
| | - David Ring
- Hand Surgery Quality Consortium (HSQC); Department of Orthopaedic Surgery, Massachusetts General Hospital/Harvard University, Boston, MA
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Waljee JF, Ladd A, MacDermid JC, Rozental TD, Wolfe SW, Calfee RP, Dennison DG, Hanel DP, Herzberg G, Hotchkiss R, Jupiter JB, Kaufmann RA, Lee SK, Ozer K, Ring DC, Ross M, Stern PJ. A Unified Approach to Outcomes Assessment for Distal Radius Fractures. J Hand Surg Am 2016; 41:565-73. [PMID: 26952734 DOI: 10.1016/j.jhsa.2016.02.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 02/09/2016] [Accepted: 02/11/2016] [Indexed: 02/02/2023]
Abstract
Distal radius fractures are one of the most common upper extremity injuries. Currently, outcome assessment after treatment of these injuries varies widely with respect to the measures that are used, timing of assessment, and the end points that are considered. A more consistent approach to outcomes assessment would provide a standard by which to assess treatment options and best practices. In this summary, we review the consensus regarding outcomes assessment after distal radius fractures and propose a systematic approach that integrates performance, patient-reported outcomes, pain, complications, and radiographs.
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Affiliation(s)
- Jennifer F Waljee
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Amy Ladd
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA
| | - Joy C MacDermid
- School of Rehabilitation Sciences, University of Western Ontario, Ontario, Canada
| | - Tamara D Rozental
- Department of Orthopaedic Surgery, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
| | - Scott W Wolfe
- Department of Orthopedic Surgery, Hospital for Special Surgery and Weill Medical College of Cornell University, New York, NY.
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Abstract
BACKGROUND Quality measures are now commonplace and are increasingly tied to financial incentives. We reviewed the existing quality measures that address the upper limb and tested the null hypothesis that structure (capacity to deliver care), process (appropriate care), and outcome (the result of care) measures are equally represented. METHODS We systematically reviewed MEDLINE/PubMed, Embase, Google Scholar, the American Academy of Orthopaedic Surgeons Clinical Practice Guidelines, the National Quality Forum, the Agency for Healthcare Research and Quality, and the Physician Quality Reporting System for quality measures addressing upper limb surgery. Measures were characterized as structure, process, or outcome measures and were categorized according to their developer and their National Strategy for Quality Improvement in Health Care (National Quality Strategy) priority as articulated by the U.S. Department of Health & Human Services. RESULTS We identified 134 quality measures addressing the upper limb: 131 (98%) process and three (2%) outcome measures. The majority of the process measures address the National Quality Strategy priority of effective clinical care (90%), with the remainder addressing communication and care coordination (5%), person and caregiver-centered experience and outcomes (4%), and community/population health (1%). CONCLUSIONS Our review identified opportunities to develop more measures in the structure and outcome domains as well as measures addressing patient and family engagement, public health, safety, care coordination, and efficient use of resources. The most common existing measures-process measures addressing care-might not be the best measures of upper limb surgery quality given the relative lack of evidence for their use in care improvement.
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Affiliation(s)
- Robin N Kamal
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - David Ring
- Department of Orthopaedic Surgery, Massachusetts General Hospital/Harvard University, Boston, Massachusetts
| | - Edward Akelman
- Department of Orthopaedic Surgery, Rhode Island Hospital/Brown University, Providence, Rhode Island
| | - Jeffrey Yao
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - David S Ruch
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Marc Richard
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Amy Ladd
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Christopher Got
- Department of Orthopaedic Surgery, Rhode Island Hospital/Brown University, Providence, Rhode Island
| | - Philip Blazar
- Department of Orthopaedic Surgery, Brigham and Women's Hospital/Harvard University, Boston, Massachusetts
| | - Sanjeev Kakar
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Vu N, Park M, Shultz M, Ladd A, Chalfant C. Caspase‐9b Directly Interacts with c‐IAP1 to Drive an Agonist‐Independent Activation of the NF‐κB Pathway and the Enhancement of Tumorigenicity in Non‐Small Cell Lung Cancer. FASEB J 2015. [DOI: 10.1096/fasebj.29.1_supplement.894.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Ngoc Vu
- Biochemistry and Molecular BiologyVirginia Commonwealth University (VCU)VAUnited States
| | - Margaret Park
- Biochemistry and Molecular BiologyVirginia Commonwealth University (VCU)VAUnited States
- Hunter Holmes McGuire Veterans Administration Medical CenterVAUnited States
- VCU Massey Cancer CenterVAUnited States
| | - Michael Shultz
- Biochemistry and Molecular BiologyVirginia Commonwealth University (VCU)VAUnited States
- Hunter Holmes McGuire Veterans Administration Medical CenterVAUnited States
| | - Amy Ladd
- Biochemistry and Molecular BiologyVirginia Commonwealth University (VCU)VAUnited States
| | - Charles Chalfant
- Biochemistry and Molecular BiologyVirginia Commonwealth University (VCU)VAUnited States
- Hunter Holmes McGuire Veterans Administration Medical CenterVAUnited States
- VCU Massey Cancer CenterVAUnited States
- VCU Johnson CenterVAUnited States
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Goldhahn J, Beaton D, Ladd A, Macdermid J, Hoang-Kim A. Recommendation for measuring clinical outcome in distal radius fractures: a core set of domains for standardized reporting in clinical practice and research. Arch Orthop Trauma Surg 2014; 134:197-205. [PMID: 23728832 DOI: 10.1007/s00402-013-1767-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Lack of standardization of outcome measurement has hampered an evidence-based approach to clinical practice and research. METHODS We adopted a process of reviewing evidence on current use of measures and appropriate theoretical frameworks for health and disability to inform a consensus process that was focused on deriving the minimal set of core domains in distal radius fracture. RESULTS We agreed on the following seven core recommendations: (1) pain and function were regarded as the primary domains, (2) very brief measures were needed for routine administration in clinical practice, (3) these brief measures could be augmented by additional measures that provide more detail or address additional domains for clinical research, (4) measurement of pain should include measures of both intensity and frequency as core attributes, (5) a numeric pain scale, e.g. visual analogue scale or visual numeric scale or the pain subscale of the patient-reported wrist evaluation (PRWE) questionnaires were identified as reliable, valid and feasible measures to measure these concepts, (6) for function, either the Quick Disability of the arm, shoulder and hand questionnaire or PRWE-function subscale was identified as reliable, valid and feasible measures, and (7) a measure of participation and treatment complications should be considered core outcomes for both clinical practice and research. CONCLUSION We used a sound methodological approach to form a comprehensive foundation of content for outcomes in the area of distal radius fractures. We recommend the use of symptom and function as separate domains in the ICF core set in clinical research or practice for patients with wrist fracture. Further research is needed to provide more definitive measurement properties of measures across all domains.
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Affiliation(s)
- Jörg Goldhahn
- Institute for Biomechanics of ETH Zurich, Zurich, Switzerland
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34
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Lee J, Ladd A, Hagert E. Immunofluorescent triple-staining technique to identify sensory nerve endings in human thumb ligaments. Cells Tissues Organs 2011; 195:456-64. [PMID: 21832813 DOI: 10.1159/000327725] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2011] [Indexed: 12/19/2022] Open
Abstract
Ligament innervation purportedly plays a critical role in stability, proprioception and pathology of joints with minimal bony constraints. The human thumb carpometacarpal (CMC) joint is such a joint: with a complex saddle configuration and wide circumduction, its constraint is primarily ligamentous and it is prone to osteoarthritis. CMC reconstruction is the most commonly performed arthritis surgery in the upper extremity. Little, however, is known about CMC ligament innervation. We describe a novel triple-staining immunofluorescence technique using the markers for low-affinity neurotrophin receptor p75, the pan-neuronal marker protein gene product (PGP) 9.5 and 4',6'-diamidino-2-phenylindole (DAPI) to simultaneously detect and differentiate between specific sensory nerve endings: the Pacini corpuscles, the Ruffini endings and nerve fascicles. Five primary CMC ligaments (dorsal radial, dorsal central, posterior oblique, anterior oblique and ulnar collateral ligaments) were harvested from 10 fresh-frozen human cadaver hands. Following paraffin sectioning, each ligament was stained using a triple-stain technique and imaged with fluorescence microscopy. Multidimensional acquisition permitted simultaneous capture of images at different wavelengths. Pacini corpuscles were distinguished by their distinct p75 immunoreactive capsules, and Ruffini endings by their overlapping p75 and PGP9.5 immunoreactive dendritic nerve endings. Simultaneous use of PGP9.5, p75 and DAPI immunofluorescence to analyze innervation patterns in human ligaments provides descriptive analysis of staining patterns and receptor structure as well as clues as to the proprioceptive function of CMC ligaments and the joint as a whole. Our novel findings of CMC ligament innervation augment the study of normal and pathological joint mechanics in this joint so prone to osteoarthritis.
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Affiliation(s)
- Julia Lee
- Department of Orthopaedic Surgery, Chase Hand Center, Stanford University, Stanford, CA, USA
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35
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Abstract
INTRODUCTION A hand and wrist disorder affects a patient's overall well-being and health-status. One concept serves as the foundation for all further consideration: in order to have confidence in your results when assessing patients with wrist and hand limitations, the clinician and researcher must choose standardised patient-oriented instruments that address the primary aims of the study. In this paper, we assess the quality of reviews published on patient oriented instruments in current use for assessing function of the hand and wrist joint. We highlight features of commonly used scales that improve readers' confidence in the choice and application of these outcome instruments. METHODS A literature search (1950-January 2010) was performed using the MESH terms: hand (strength, injuries, joints) and wrist (injuries, joint) combined with outcome and process assessment (questionnaires, outcome assessment, health status indicators, quality of life). Titles and abstracts (n=341) were screened by two reviewers independently. The GRADE approach was used to assess the quality of ten reviews and the inclusion of clinimetric properties were assessed using the COSMIN checklist. RESULTS We included three systematic reviews rated moderate to high (2 hand injury instrument reviews and 1 wrist fracture outcome review). Recommendations of use and an overview are provided for the disability of the arm, shoulder and hand questionnaire (DASH), QuickDASH, the Michigan hand questionnaire (MHQ), the patient-rated wrist hand evaluation outcome questionnaire (PRWHE) and the carpal tunnel questionnaire (CTQ) scales with established measurement properties. CONCLUSIONS The DASH, a region-specific 30-item questionnaire is the most widely tested instrument in patients with wrist and hand injuries. The MHQ can provide good value to patients with hand injuries. Although, the CTQ is the most sensitive to clinical change, the DASH and MHQ have shown to be sufficiently responsive to outcome studies of carpal tunnel syndrome. The PRWHE has a good construct validity and responsiveness, which is only slightly better than the DASH to assess patients with wrist injuries. As the quality of patient-oriented validation continues to increase then the instruments can be selected more carefully. We will then be able to see that the future orthopaedic care of patients with hand and wrist injuries may also improve.
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Affiliation(s)
- A Hoang-Kim
- St. Michael's Hospital, University of Toronto, Institute of Medical Science, Toronto, Canada.
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Zhang X, Ladd A, Dragoescu E, Budd WT, Ware JL, Zehner ZE. MicroRNA-17-3p is a prostate tumor suppressor in vitro and in vivo, and is decreased in high grade prostate tumors analyzed by laser capture microdissection. Clin Exp Metastasis 2009; 26:965-79. [PMID: 19771525 DOI: 10.1007/s10585-009-9287-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2009] [Accepted: 09/04/2009] [Indexed: 12/23/2022]
Abstract
MicroRNAs (miRs) are a novel class of RNAs with important roles in regulating gene expression. To identify miRs controlling prostate tumor progression, we utilized unique human prostate sublines derived from the parental P69 cell line, which differ in their tumorigenic properties in vivo. Grown embedded in laminin-rich extracellular matrix (lrECM) gels these genetically-related sublines displayed drastically different morphologies correlating with their behaviour in vivo. The non-tumorigenic P69 subline grew as multicellular acini with a defined lumen and basal/polar expression of relevant marker proteins. M12, a highly tumorigenic, metastatic derivative, grew as a disorganized mass of cells with no polarization, whereas the F6 subline, a weakly tumorigenic, non-metastatic M12 variant, reverted to acini formation akin to the P69 cell line. These sublines also differed in expression of vimentin, which was high in M12, but low in F6 and P69 sublines. Analysis of vimentin's conserved 3'-UTR suggested several miRs that could regulate vimentin expression. The lack of miR-17-3p expression correlated with an increase in vimentin synthesis and tumorigenicity. Stable expression of miR-17-3p in the M12 subline reduced vimentin levels 85% and reverted growth to organized, polarized acini in lrECM gels. In vitro motility and invasion assays suggested a decrease in tumorigenic behaviour, confirmed by reduced tumor growth in male athymic, nude mice dependent on miR-17-3p expression. Analysis of LCM-purified clinical human prostatectomy specimens confirmed that miR-17-3p levels were reduced in tumor cells. These results suggest that miR-17-3p functions as a tumor suppressor, representing a novel target to block prostate tumor progression.
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Affiliation(s)
- Xueping Zhang
- Department of Biochemistry & Molecular Biology and The Massey Cancer Center, School of Medicine, VCU Medical Center, Richmond, VA, 23298, USA
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Wadey VMR, Ladd A, Dev P, Walker D. What orthopaedic surgery residents need to know about the hand and wrist? BMC Med Educ 2007; 7:33. [PMID: 17919336 PMCID: PMC2175502 DOI: 10.1186/1472-6920-7-33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2006] [Accepted: 10/05/2007] [Indexed: 05/25/2023]
Abstract
BACKGROUND To develop a Core Curriculum for Orthopaedic Surgery; and to conduct a national survey to assess the importance of curriculum items as judged by orthopaedic surgeons with primary affiliation non-academic. Attention for this manuscript was focused on determining the importance of topics pertaining to adult hand and wrist reconstruction. METHODS A 281-item questionnaire was developed and consisted of three sections: 1) Validated Musculoskeletal Core Curriculum; 2) Royal College of Physician and Surgeons of Canada (RCPSC) Specialty Objectives and; 3) A procedure list. A random group of 131 [out of 156] orthopaedic surgeons completed the questionnaire. Data were analyzed descriptively and quantitatively using histograms, a Modified Hotel ling's T2-statistic 1 with p-value determined by a permutation test, and the Benjamini-Hochberg/Yekutieli procedure RESULTS 131/156 (84%) orthopaedic surgeons participated in this study. 27/32 items received an average mean score of at least 3.0/4.0 by all respondents thus suggesting that 84% of the items are either "probably important" or "important" to know by the end of residency (SD range 0.007-0.228). The Benjamini-Hochberg procedure demonstrated that for 80% of the 32 x 31/2 = 496 possible pairs of hand and wrist questions did not appear to demonstrate the same distribution of ratings given that one question was different from that of another question. CONCLUSION This study demonstrates with reliable statistical evidence, agreement on the importance of 27/32 items pertaining to hand and wrist reconstruction is included in a Core Curriculum for Orthopaedic Surgery. Residency training programs need ensure that educational opportunities focusing on the ability to perform with proficiency procedures pertaining to the hand and wrist is taught and evaluated in their respective programs.
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Affiliation(s)
- Veronica MR Wadey
- Orthopaedic Surgeon, Assistant Professor, Department of Surgery, Division of Orthopaedic Surgery, The Faculty of Medicine, University of Toronto, 43 Wellesley Street East, Suite 315, Toronto ON M4Y 1H1, Canada
| | - Amy Ladd
- Department of Orthopaedic Surgery, Stanford University, Stanford, USA
| | - Parvati Dev
- Department of Medicine, Stanford University Medical Media and Technologies, Stanford University, Stanford, USA
| | - Decker Walker
- School of Education, Stanford University, Stanford, USA
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Abstract
BACKGROUND New techniques in imaging and surgery have made 3-dimensional anatomical knowledge an increasingly important goal of medical education. This study compared the efficacy of 2 supplemental, self-study methods for learning shoulder joint anatomy to determine which method provides for greater transfer of learning to the clinical setting. METHODS Two groups of medical students studied shoulder joint anatomy using either a second-generation virtual reality surgical simulator or images from a textbook. They were then asked to identify anatomical structures of the shoulder joint as they appeared in a videotape of a live arthroscopic procedure. RESULTS The mean identification scores, out of a possible score of 7, were 3.1 +/- 1.3 for the simulator group and 2.9 +/- 1.5 for the textbook group (P = 0.70). Student ratings of the 2 methods on a 5-point Likert scale were significantly different. The simulator group rated the simulator more highly as an effective learning tool than the textbook group rated the textbook (means of 3.2 +/- 0.7 and 2.6 +/- 0.5, respectively, P = 0.02). Furthermore, the simulator group indicated that they were more likely to use the simulator as a learning tool if it were available to them than the textbook group was willing to use the textbook (means of 4.0 +/- 1.2 and 3.0 +/- 0.9, respectively, P = 0.02). CONCLUSION Our results show that this surgical simulator is at least as effective as textbook images for learning anatomy and could enhance student learning through increased motivation. These findings provide insight into simulator development and strategies for learning anatomy. Possible explanations and future research directions are discussed.
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Affiliation(s)
- S Hariri
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA
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Cassidy C, Jupiter JB, Cohen M, Delli-Santi M, Fennell C, Leinberry C, Husband J, Ladd A, Seitz WR, Constanz B. Norian SRS cement compared with conventional fixation in distal radial fractures. A randomized study. J Bone Joint Surg Am 2003; 85:2127-37. [PMID: 14630841 DOI: 10.2106/00004623-200311000-00010] [Citation(s) in RCA: 126] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND A prospective, randomized multicenter study was conducted to evaluate closed reduction and immobilization with and without Norian SRS (Skeletal Repair System) cement in the management of distal radial fractures. Norian SRS is a calcium-phosphate bone cement that is injectable, hardens in situ, and cures by a crystallization reaction to form dahllite, a carbonated apatite equivalent to bone mineral. METHODS A total of 323 patients with a distal radial fracture were randomized to treatment with or without Norian SRS cement. Stratification factors included fracture type (intra-articular or extra-articular), hand dominance, bone density, and the surgeon's preferred conventional treatment (cast or external fixator). The subjects receiving Norian SRS underwent a closed reduction followed by injection of the cement percutaneously or through a limited open approach. Wrist motion, beginning two weeks postoperatively, was encouraged. Control subjects, who had not received a Norian SRS injection, underwent closed reduction and application of a cast or external fixator for six to eight weeks. Supplemental Kirschner wires were used in specific instances in both groups. Patients were followed clinically and radiographically at one, two, four, and between six and eight weeks and at three, six, and twelve months. Patients rated pain and the function of the hand with use of a visual analog scale. Quality of life was assessed with use of the Short Form-36 (SF-36) health status questionnaire. Complications were recorded. RESULTS Significant clinical differences were seen at six to eight weeks postoperatively, with better grip strength, wrist range of motion, digital motion, use of the hand, and social and emotional function, and less swelling in the patients treated with Norian SRS than in the control group (p < 0.05). By three months, these differences had normalized except for digital motion, which remained significantly better in the group treated with Norian SRS (p = 0.015). At one year, no clinical differences were detected. Radiographically, the average change in ulnar variance was greater in the patients treated with Norian SRS (+2.0 mm) than in the control group (+1.4 mm) (p < 0.02). No differences were seen in the total number of complications, including loss of reduction. The infection rate, however, was significantly higher (p < 0.001) in the control group (16.7%) than in the group treated with Norian SRS (2.5%) and the infections were always related to external fixator pins or Kirschner wires. Four patients with intra-articular extravasation of cement were identified; no sequelae were observed at twenty-four months. Cement was seen in extraosseous locations in 112 (70%) of the SRS-treated patients; loss of reduction was highest in this subgroup (37%). The extraosseous material had disappeared in eighty-three of the 112 patients by twelve months. CONCLUSIONS Our results indicate that fixation of a distal radial fracture with Norian SRS cement may allow for accelerated rehabilitation. A limited open approach and supplemental fixation with Kirschner wires are recommended. Additional or alternate fixation is necessary for complex articular fractures.
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Mulvey M, Poppers J, Ladd A, Mohr I. A herpesvirus ribosome-associated, RNA-binding protein confers a growth advantage upon mutants deficient in a GADD34-related function. J Virol 1999; 73:3375-85. [PMID: 10074192 PMCID: PMC104102 DOI: 10.1128/jvi.73.4.3375-3385.1999] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The herpes simplex virus type 1 gamma34.5 gene product and the cellular GADD34 protein both contain similar domains that can regulate the activity of eukaryotic initiation factor 2 (eIF2), a critical translation initiation factor. Viral mutants that lack the GADD34-related function grow poorly on a variety of malignant human cells, as activation of the cellular PKR kinase leads to the accumulation of inactive, phosphorylated eIF2 at late times postinfection. Termination of translation prior to the completion of the viral reproductive cycle leads to impaired growth. Extragenic suppressors that regain the ability to synthesize proteins efficiently in the absence of the viral GADD34-related function have been isolated. These suppressor alleles are dominant in trans and affect the steady-state accumulation of several viral mRNA species. We demonstrate that deregulated expression of Us11, a virus-encoded RNA-binding, ribosome-associated protein is necessary and sufficient to confer a growth advantage upon viral mutants that lack a GADD34-related function. Ectopic expression of Us11 reduces the accumulation of the activated cellular PKR kinase and allows for sustained protein synthesis. Thus, an RNA-binding, ribosome-associated protein (Us11) and a GADD34-related protein (gamma34.5) both function in a signal pathway that regulates translation by modulating eIF2 phosphorylation.
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Affiliation(s)
- M Mulvey
- Department of Microbiology and Kaplan Comprehensive Cancer Center, New York University School of Medicine, New York, New York 10016, USA
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Ladd A, Walfield A, Tsong YY, Thau R. Active immunization against LHRH alone or combined with LHRH-analogue treatment impedes growth of androgen-dependent prostatic carcinoma. Am J Reprod Immunol 1995; 34:200-6. [PMID: 8561879 DOI: 10.1111/j.1600-0897.1995.tb00939.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
PROBLEM To determine whether active immunization against LHRH can serve as treatment for androgen-dependent prostatic carcinoma. METHOD Male rats of Copenhagen X Fisher strain, implanted with Dunning R-3327 prostatic carcinoma cells were either immunized against LHRH, treated with LHRH-antagonist, or received a combined treatment of active immunization against LHRH and LHRH-antagonist. RESULTS Testicular histology was consistent with infertility in all treatment groups. The rate of tumor growth was inhibited by all three treatment regimens. Tumor size increased by 3.8 +/- 1.4 cm2 in the LHRH-antagonist group, 3.2 +/- 1.1 cm2 in the immunized group, and 1.0 +/- 0.4 cm2 in the combined treatment group, as compared to 8.2 +/- 2.6 cm2 in non-treated control group. CONCLUSION LHRH-antagonist administration combined with immunization against LHRH appeared to exert a synergistic effect. This may be due to the blockade of prostatic LHRH-like receptors by the antagonist, while androgen depletion was rapidly achieved by LHRH-antagonist, and maintained by continued gonadotropin suppression caused by active immunization against LHRH once antagonist treatment had been discontinued.
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Affiliation(s)
- A Ladd
- Population Council, Center for Biomedical Research, New York, New York, USA
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Schneider D, Patsy B, Ladd A, Prince J. Document imaging: long-term solution or stop-gap measure? Healthc Inform 1995; 12:58-60, 62. [PMID: 10141978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Just what exactly does a "paperless office" mean? To some healthcare professionals, it means just that-no use of paper documents whatsoever. But to others, "paperless" more or less means using paper documents to reach a higher level of electronic recording, in other words-document imaging. We asked four industry insiders to discuss their views and opinions on the use of document imaging in healthcare. Their comments follow.
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Ladd A, Tsong YY, Walfield AM, Thau R. Development of an antifertility vaccine for pets based on active immunization against luteinizing hormone-releasing hormone. Biol Reprod 1994; 51:1076-83. [PMID: 7888486 DOI: 10.1095/biolreprod51.6.1076] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Male dogs and cats were immunized against LHRH in order to evaluate the feasibility of an immunological approach to pet contraception. In the first study, dogs were immunized with 100, 500, or 2500 micrograms of LHRH conjugated to tetanus toxoid. A significant decline in serum testosterone (T) levels was observed in all immunized dogs, reaching castration levels in some animals by Week 4 and remaining suppressed in all the immunized dogs through the course of the study. Testicular histology suggested arrest of spermatogenesis (infertility). The effects of "immunological castration" were reversible (study 2): steroidogenesis suppressed by "immunological castration" was restored as antibody titers declined. Effective antibodies were rapidly reinduced in dogs by a single injection of LHRH1-TT. In contrast, the level of antibodies induced in male cats (study 3) was not sufficient for "immunological castration." The conclusion was that active immunization against LHRH could provide a cost-effective, nonsurgical, reversible means to control the fertility of companion animals.
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Affiliation(s)
- A Ladd
- United Biomedical, Inc., Hauppauge, New York 11788
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Affiliation(s)
- A Ladd
- Population Council, Center for Biomedical Research, Hanppauge, NY
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Taylor GS, Ladd A, James J, Greene B, English D. Characterization of phosphatidic acid phosphohydrolase in neutrophil subcellular fractions. Biochim Biophys Acta 1993; 1175:219-24. [PMID: 8418897 DOI: 10.1016/0167-4889(93)90026-l] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
This investigation was designed to confirm the presence of PA phosphohydrolase in human neutrophils and to determine the distribution and characteristics of the enzyme in soluble and particulate subcellular fractions of disrupted neutrophils. Enzyme activity was detected in unseparated extracts of sonicated neutrophils. The majority of the recovered activity was recovered in a particulate fraction rich in neutrophil plasma-membrane markers; moderate levels (20%) of the total activity were recovered in the cytosol. While Mg2+ markedly potentiated the cytosolic but not the particulate activity, Ca2+ moderately inhibited both the cytosolic and particulate enzymes. The plasma-membrane-associated activity was absolutely dependent on detergent (0.5% Triton X-100) and displayed an apparent Km of 62 microM for phosphatidic acid. Enzyme activity was markedly inhibited by NaF, not influenced by excess glycerophosphate and slightly attenuated by propranolol, an inhibitor of PA phosphohydrolase in other systems. Preincubation of plasma membranes with N-ethylmaleimide at concentrations up to 25 mM had little effect on enzyme activity. However, activity in cytosolic and microsomal fractions of neutrophils were completely abolished by preincubation with N-ethylmaleimide at concentrations of less than 5 mM. We conclude that neutrophils possess a potent PA phosphohydrolase localized in their plasma membranes. Metabolism of cellular second-messengers by this enzyme may exert a profound effect on the functions of stimulated neutrophils.
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Affiliation(s)
- G S Taylor
- Bone Marrow Transplantation Laboratory, Methodist Hospital of Indiana, Indianapolis 46202
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Kumar N, Didolkar AK, Ladd A, Thau R, Monder C, Bardin CW, Sundaram K. Radioimmunoassay of 7 alpha-methyl-19-nortestosterone and investigation of its pharmacokinetics in animals. J Steroid Biochem Mol Biol 1990; 37:587-91. [PMID: 2278844 DOI: 10.1016/0960-0760(90)90405-a] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
A method for the measurement of 7 alpha-methyl-19-nortestosterone (7MENT) in serum/plasma by radioimmunoassay (RIA) is described. The antiserum, raised against 7 alpha-methyl-19-nortestosterone-3-O-oxime-bovine serum albumin, had a low titer (final dilution = 1:4500) and low affinity (Ka = 1.17 x 10(9) l/mol) but showed little or no cross-reactivity with several of the steroids tested. The sensitivity of the RIA was 28.2 pg/ml and the mean recovery of added cold steroid was 86 to 100%. Intra- and inter-assay coefficients of variation ranged from 4.3 to 7.3% and 7.3 to 8.4%, respectively. This RIA was used to follow plasma 7MENT levels after a single i.v. injection of the steroid in rats and rabbits. The metabolic clearance rates (MCR) of 7MENT as determined from the plasma disappearance curve for rats and rabbits were 50 l/day and 336 l/day, respectively. The MCR of 7MENT in rats and rabbits lies in the same range as for testosterone. When compared to other nortestosterone derivatives such as norethisterone, 7MENT is metabolized relatively faster.
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Affiliation(s)
- N Kumar
- Center for Biomedical Research, Population Council, New York, NY 10021
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Abstract
UNLABELLED Active immunization against LHRH is a promising method of contraception for men. In order to be acceptable, sufficient amounts of anti-LHRH antibodies must be induced rapidly after vaccination. In previously reported animal studies, we found that it took considerable time (up to 5 months) to obtain antibody titers (AT) that were sufficiently high for complete suppression of spermatogenesis. The possibility of accelerating the immune response to LHRH by increasing the dose of immunogen was investigated in the male rat. Six doses of LHRH conjugated to tetanus toxoid (TT) in the 10 position (LHRH10-TT), ranging from 2.5 to 612 micrograms, and three doses of LHRH1-TT (50 to 612 micrograms) were tested. The magnitude of the immune response did not depend on the dose of the antigen, provided a threshold dose had been surpassed. Antigenicity of LHRH conjugated to TT at either the 1-, 6-, or 10-position was compared in rats and rabbits. In both species LHRH1-TT induced sufficient antibody concentrations to suppress pituitary gonadotropins (LH and FSH) and, subsequently, serum testosterone (T) levels faster than either the 6- or 10-conjugates. Only materials permitted for use in humans were utilized in these experiments. CONCLUSION Active immunization against LHRH conjugated to TT at the 1-position has potential as a fast, convenient method of male contraception.
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Affiliation(s)
- A Ladd
- Population Council, New York, NY 10021
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Abstract
The possibility of immunological suppression of spermatogenesis while normal libido is maintained by exogenous androgen supplementation was tested in male rats. Neither short- nor long-term treatment with androgen (testosterone-17-trans-4-N-butyl-cyclohexane carboxylate) alone influenced fertility. Active immunization against LHRH administered simultaneously with exogenous androgen supplement caused infertility in 100% of the tested animals, all of which displayed normal sexual behavior. The atrophy of the testes and accessory sex organs was reversible.
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Affiliation(s)
- A Ladd
- Population Council, New York, NY 10021
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Ladd A, Prabhu G, Tsong YY, Probst T, Chung W, Thau RB. Active immunization against gonadotropin-releasing hormone combined with androgen supplementation is a promising antifertility vaccine for males. Am J Reprod Immunol Microbiol 1988; 17:121-7. [PMID: 3144190 DOI: 10.1111/j.1600-0897.1988.tb00215.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Male rats and rabbits were immunized against gonadotropin-releasing hormone (GnRH) conjugated to tetanus toxoid (GnRH10-TT) using only materials approved for humans. Testosterone (T)-releasing implants or the long-lasting T ester testosterone-17-trans-4-n-butyl-cyclohexane carboxylate (TE) was used as supplemental androgen for maintaining libido. Immunization against GnRH10-TT effectively suppressed fertility (spermatogenesis) in rats and rabbits. Neither T nor TE administration restored fertility. Both androgens were effective in maintaining normal libido in rats. TE, which is not hydrolyzed in rabbits, was less effective in maintaining normal ejaculatory behavior in this species. Active immunization against GnRH could be a convenient and cost-effective method of fertility control in males.
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Affiliation(s)
- A Ladd
- Population Council, New York, NY 10021
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