Healthcare Providers' Knowledge of Evidence-Based Treatment for Tobacco Dependence, DocStyles 2020

PURPOSE

Although smoking cessation reduces the risk of all-cause mortality, evidence-based cessation treatments are underused. This study examined healthcare provider knowledge of evidence-based cessation treatments and associations between knowledge and clinical practice characteristics.

DESIGN

Cross-sectional survey.

SETTING

2020 DocStyles.

SUBJECTS

1480 U.S. healthcare providers.

MEASURES

Provider knowledge of availability of tobacco use disorder diagnostic criteria, clinical practice guideline availability, treatment efficacy, evidence-based counseling modalities, and medications approved by the U.S. Food and Drug Administration (FDA).

ANALYSIS

Adjusted odds ratios (aORs), adjusted for personal and clinical practice characteristics.

RESULTS

Less than half of respondents demonstrated high knowledge of availability of diagnostic criteria (36.8%), cessation treatment efficacy (33.2%), evidence-based counseling modalities (5.6%), and FDA-approved medications (40.1%). Significant differences were found between specialties: compared to internists, family physicians were less likely to have low knowledge of medications (aOR = .69, 95% CI = .53, .90) and obstetricians/gynecologists were more likely to have low knowledge of medications (aOR = 2.62, 95% CI = 1.82, 3.76). Overall, few associations between knowledge and clinical practice characteristics were identified.

CONCLUSION

Most providers had low knowledge of the topics of interest, with little variation across clinical practice characteristics, indicating room for improvement. Efforts to improve provider knowledge of evidence-based treatments are an important component of a comprehensive approach to improving delivery and use of cessation interventions and increasing tobacco cessation.

Perioperative periprosthetic femur fracture associated with direct anterior total hip arthroplasty using metaphyseal fit and fill stem

INTRODUCTION

This study aims to identify radiographic and clinical risk factors of perioperative periprosthetic femur fracture associated with the direct anterior approach (DAA) using a metaphyseal fit and fill stem. We hypothesize stem malalignment with this femoral implant places increased stress on the medial calcar region, which leads to an increased risk of periprosthetic fracture.

METHODS

We compared patients with periprosthetic femur fractures following DAA total hip arthroplasty (THA) utilizing the Echo Bi-Metric Microplasty Stem (Zimmer Biomet, Warsaw, IN) to a cohort of patients who did not sustain a periprosthetic fracture from five orthopedic surgeons over four years. Postoperative radiographs were evaluated for stem alignment, neck cut level, Dorr classification, and the presence of radiographic pannus. Univariate and logistic regression analyses were performed. Demographic and categorical variables were also analyzed.

RESULTS

Fourteen hips sustained femur fractures, including nine Vancouver B2 and five AG fractures. Valgus stem malalignment, proud stems, extended offset, and patients with enlarged radiographic pannus reached statistical significance for increased fracture risk. Low femoral neck cut showed a trend toward statistical significance.

CONCLUSION

Patients undergoing DAA THA using a metaphyseal fit and fill stem may be at increased risk of perioperative periprosthetic fracture when the femoral stem sits proudly in valgus malalignment with extended offset and when an enlarged pannus is seen radiographically. This study identifies a specific pattern in the Vancouver B2 fracture cohort with regard to injury mechanism, time of injury, and fracture pattern, which may be attributed to coronal malalignment of the implant.

Comparing Perceived Radiograph Quality Between Radiologic Technologists and Orthopedic Surgeons

PURPOSE

To determine if there is a discrepancy between how orthopedic surgeons perceive the quality of plain radiographs compared with that of radiologic technologists.

METHODS

A prospective survey was developed including 42 deidentified plain radiographs. Included radiographs were of varying anatomical regions, patient positioning, and radiographic parameters. Participants were requested to score each radiograph on a scale from 1 (very poor) to 100 (very good) based on their overall subjective definition of radiographic quality.

RESULTS

Multiple analyses of variance showed that out of the 42 radiographs evaluated, 13 images had significant differences in how they were scored by each group. Technologists provided lower image quality scores for 11 images compared with the orthopedic residents and attending surgeons. Two images were scored significantly higher by the attendings compared with the technologists or residents. Of the 42 images, 29 were scored similarly by the 3 groups.

DISCUSSION

This study is novel because it explored perceived radiograph quality between attending orthopedic surgeons, orthopedic surgery residents, and radiologic technologists. Review of current literature revealed comparisons of radiography quality assessments between radiologic technologists and radiologists. Like the findings of the authors of the current report, the literature analysis demonstrated that radiologic technologists and radiologists appear to agree on what was considered a quality image, but technologists were more reluctant to accept images of lower quality than were radiologists. These authors believe the present study helps further establish that orthopedic surgeons typically order repeat imaging for reasons other than image quality.

CONCLUSION

Orthopedic surgeons and radiologic technologists appear to agree in a subjective manner on a quantitative scale. Radiologic technologists tended to be more critical than were orthopedic surgeons in judging radiograph quality, contrary to the authors' original hypothesis.

A Radiographic Abdominal Pannus Sign is Associated With Postoperative Complications in Anterior THA

BACKGROUND

Numerous studies have shown that elevated BMI is associated with adverse outcomes in THA; however, BMI alone does not adequately represent a patient's adipose and soft tissue distribution, especially when the direct-anterior approach is evaluated. Local soft tissue and adipose, especially in the peri-incisional region, has an unknown impact on patient outcomes after direct-anterior THA. Moreover, there is currently no known evaluation method to estimate the quantity of local soft tissue and adipose tissue. The current study introduced a new radiographic parameter that is measurable on supine AP radiographs: the abdominal pannus sign.

QUESTION/PURPOSE

Are patients who have an abdominal pannus extending below the upper (cephalad) border of the symphysis pubis more likely to experience problems after anterior-approach THA that are plausibly associated with that finding, including infections resulting in readmission, wound complications resulting in readmission, fractures, or longer surgical time, than patients who do not demonstrate this radiographic sign?

METHODS

Between 2015 and 2020, five surgeons performed 727 primary direct-anterior THAs. After exclusion criteria were applied, 596 procedures were included. Of those, we obtained postoperative radiographs in the postanesthesia care unit in 100% of procedures (596 of 596), and 100% of radiographs (596) were adequate for review in this retrospective study. The level of the pannus in relation to the pubic symphysis was assessed on immediate supine postoperative AP radiographs of the pelvis: above (pannus sign 1), between the upper and lower borders (pannus sign 2), or below the level of the pubic symphysis (pannus sign 3). In this study, we combined pannus signs 2 and 3 into a single group for analysis not only because there was a limited number of patients in each group, but also because there was no statistically significant difference between the two groups. Pannus sign 1 was identified in 82% of procedures (486 of 596), and pannus sign ≥ 2 was identified in 18% (110). We compared the groups (pannus sign 1 versus pannus sign ≥ 2) in terms of the percentage of patients who experienced problems within 90 days of THA that might be associated with that physical finding, including infections resulting in readmission including subcutaneous, subfascial, and prosthetic joint infections; wound complications resulting in readmission, defined as dehiscence or delayed healing; and all fractures, and we compared the groups in terms of surgical time-that is, the cut-to-close time.

RESULTS

Patients with a pannus sign of ≥ 2 were more likely than those with a pannus sign of 1 to have a postoperative infection (6.4% [seven of 110 procedures] versus 0.6% [three of 486], odds ratio 10.96 [95% confidence interval (CI) 2.83 to 42.38]; p < 0.01), wound complications (0.9% [one of 110] versus 0% [0 of 486] with an infinite odds ratio [95% CI indeterminate]; p = 0.18), and fractures (4.5% [five of 110] versus 0% [0 of 486], with an infinite odds ratio [95% CI indeterminate]; p < 0.01). The mean surgical time was longer in patients with a pannus sign of ≥ 2 than it was in those with a pannus sign of 1 (128 ± 25.3 minutes versus 118 ± 27.5 minutes, mean difference 10 minutes; p < 0.01).

CONCLUSION

Based on these findings, patients who have an abdominal pannus that extends below the upper (cephalad) edge of the pubic symphysis are at an increased risk of experiencing serious surgical complications. If THA is planned in these patients, an approach other than the direct-anterior approach should be considered. Surgeons performing THA who do not obtain supine radiographs preoperatively should use a physical examination to evaluate for this finding, and if it is present, they should use an approach other than the direct-anterior approach to minimize the risk of these complications. Future studies might compare the abdominal pannus sign using standing radiographs, which are used more often, with other well-documented associated risk factors such as elevated BMI or higher American Society of Anesthesiologists classification.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Occult clavicle osteomyelitis caused by Cutibacterium acnes (C. acnes) after coracoclavicular ligament reconstruction: A case report and review of the literature

INTRODUCTION

Clavicle osteomyelitis is a rare, but serious complication following operative repair of acromioclavicular (AC) joint separations. Cutibacterium Acnes (C. acnes) is rarely a causative pathogen in clavicle osteomyelitis and diagnosis can be challenging due to the indolent nature of this organism.

CASE PRESENTATION

A 45-50 year old female with a chronic AC joint separation underwent an open coracoclavicular reconstruction using semitendinosus allograft and FiberTape (Arthrex, Naples, FL). At the six month follow up, the patient complained of mild persistent pain. Imaging demonstrated widening of the medial suture tunnel with distal clavicle osteolysis, which was concerning for osteomyelitis. This was successfully treated with implant removal revision surgery and additional intravenous antibiotics. Cultures of the graft material were positive for C. acnes. The patient continued to have osteolysis of the distal left clavicle for a period of time despite resolution of osteomyelitis.

DISCUSSION

C. acnes osteomyelitis of the clavicle is difficult to diagnose because of its vague associated symptoms when implicated in infections. There are no known obvious predisposing factors for C. acnes clavicle osteomyelitis. Literature suggests management should include aggressive irrigation and debridement, removal of any hardware, and extended intravenous antibiotic administration.

CONCLUSION

C. acnes clavicular osteomyelitis is uncommon, thus established treatment guidelines have not yet been formed. Revision surgery to remove graft material, irrigate, and debride in addition to antibiotic treatment was successful for our patient. Additional pathologic manifestations of C. acnes infections could include continued clavicular erosion post-clearance of infection, although further investigation is necessary.

Primary Repair of the Medial Collateral Ligament with a Double Row Suture Technique and Suture Tape Augmentation for Acute Tibial-Sided Injuries

The management of medial collateral ligament (MCL) injuries has evolved during the past 30 years. Most heal reliably with conservative management. The treatment of MCL sprains with concomitant other ligamentous injuries continues to be controversial. Surgical management of chronic laxity of the medial structures can be quite difficult, and therefore anatomic repair of the medial support structures in the acute setting is preferred when indicated. Complete avulsion of the superficial and deep MCL from the tibia with disruption of the meniscal coronary ligament have a poor prognosis with non-operative treatment and may be optimally managed with acute surgical repair for improved valgus stability. A recent review demonstrated that there is a role for primary MCL repair for select patients. This technique addresses complete avulsions from the tibia, using multiple anchors for anatomic reattachment of the deep and superficial MCL, SutureBridge construct to enhance footprint compression, and suture tape to augment the MCL repair. Advantages of this technique include utilization of suture tape augmentation to allow for early range of motion, maintenance of the native MCL to preserve proprioception, and repair in the acute setting for faster recovery.

Influence of the concentration of CO2 and SO2 on the absorption of CO2 by a lithium orthosilicate-based absorbent

A novel, high temperature solid absorbent based on lithium orthosilicate (Li(4)SiO(4)) has shown promise for postcombustion CO(2) capture. Previous studies utilizing a clean, synthetic flue gas have shown that the absorbent has a high CO(2) capacity, >25 wt %, along with high absorption rates, lower heat of absorption and lower regeneration temperature than other solids such as calcium oxide. The current effort was aimed at evaluating the Li(4)SiO(4) based absorbent in the presence of contaminants found in typical flue gas, specifically SO(2), by cyclic exposure to gas mixtures containing CO(2), H(2)O (up to 25 vol. %), and SO(2) (up to 0.95 vol. %). In the absence of SO(2), a stable CO(2) capacity of ∼ 25 wt % over 25 cycles at 550 °C was achieved. The presence of SO(2), even at concentrations as low as 0.002 vol. %, resulted in an irreversible reaction with the absorbent and a decrease in CO(2) capacity. Analysis of SO(2)-exposed samples revealed that the absorbent reacted chemically and irreversibly with SO(2) at 550 °C forming Li(2)SO(4). Thus, industrial application would require desulfurization of flue gas prior to contacting the absorbent. Reactivity with SO(2) is not unique to the lithium orthosilicate material, so similar steps would be required for other absorbents that chemically react with SO(2).

Regulators of serine/threonine protein phosphatases at the dawn of a clinical era?

Reversible phosphorylation is a key mechanism for regulating the biological activity of many human proteins that affect a diverse array of cellular processes, including protein-protein interactions, gene transcription, cell-cycle progression and apoptosis. Once viewed as simple house keeping enzymes, recent studies have made it eminently clear that, like their kinase counterparts, protein phosphatases are dynamic and highly regulated enzymes. Therefore, the development of compounds that alter the activity of specific phosphatases is rapidly emerging as an important area in drug discovery. Because >98% of protein phosphorylation occurs on serine and threonine residues, the identification of agents that alter the activity of specific serine/threonine phosphatases seems especially promising for drug development in the future. This review is focused on the enzymes encoded by the PPP-gene family, which includes PP1, PP2A, PP2B, PP4, PP5, PP6 and PP7. The structure/functions of human phosphatases will be addressed briefly, as will the natural product inhibitors of PP1-PP6 (e.g. okadaic acid, microcystins, nodularin, cantharidin, calyculin A, tautomycin, and fostriecin). The development of chimeric antisense oligonucleotides that support RNAase H mediated degradation of the targeted mRNA has resulted in compounds capable of specifically suppressing the expression of PP5 (ISIS 15534) and PP1gamma 1 (ISIS 14435) in human cells. Such compounds have already proven useful for the validation of drug targets, and if difficulties associated with systemic delivery of antisense oligonucleotides can be overcome, antisense is poised to have a major impact on the clinical management of many human disorders.

Implementing and Tracking Clinical Quality Improvement in a Hospital Pharmacy

This study describes a hospital pharmacy's initiative in tracking the progress of its clinical quality-improvement programs. Using first a manual system and then an online program for tracking pharmacy consultations, information on pharmacy performance quality was collected for a two-year period. Pharmacy consultations increased from 43 in February 1999 to 266 in December 1999, peaking at 402 in August 2000. Consultations increased during each month of the year 2000 compared with the corresponding month of 1999. The majority (33%) of consultations were order clarifications, followed by drug information consults (23%), patient care encounters (13%), pharmacokinetic consults (8%), therapeutic consults (7%), renally excreted drug monitoring (4%), and consultations involving duplicate unnecessary therapy, formulary conversion, and interactions/compatability (all at 3%). Antibiotic regimen change (2%) and allergy/disease state contraindication (1%) were the least frequent types of consultations. The online tracking system provided more detail than the manual tracking system. This detail can be used to target goals and demonstrate pharmacy progress to hospital committees and accreditation agencies.

Identification of an estrogen-inducible phosphatase (PP5) that converts MCF-7 human breast carcinoma cells into an estrogen-independent phenotype when expressed constitutively

The proliferation of many estrogen receptor (ER)-positive breast cancer cells depends on estradiol, and tumors arising from these cells are often responsive initially to treatment with selective ER modulators, which produce an antiestrogen effect. However, tumors that are refractory to the antiestrogenic effects of selective ER modulators often reemerge, and the prognosis for these patients is poor because of the lack of additional effective therapy. Accordingly, deciphering the cellular events associated with estrogen-dependent growth and the subsequent outgrowth of tumors with an estrogen-independent phenotype is of considerable interest. Here we show that the expression of PP5, an evolutionarily conserved Ser/Thr phosphatase that functions as an inhibitor of glucocorticoid- and p53-induced signaling cascades leading to growth suppression, is responsive to 17beta-estradiol (E(2)) in ER-positive human breast carcinoma cells (MCF-7). Northern analysis revealed that E(2)-induced PP5 expression is blocked by treatment with tamoxifen, and a consensus ER recognition element was identified in the PP5 promoter. The PP5-ER recognition element associates with human ERs and confers E(2)-induced transcriptional activation to reporter plasmids. The specific inhibition of PP5 expression ablates E(2)-mediated proliferation in MCF-7 cells without having an apparent effect on E(2)-induced expression of c-myc or cyclin D1. Thus, although critical for cell growth, PP5 likely acts either downstream or independently of c-Myc and Cyclin D1. To further characterize the role of PP5 in E(2)-regulated growth control, we constructed stable MCF-7 cell lines in which the expression of PP5 was placed under the control of tetracycline-regulated transactivator and operator plasmids. Studies with these cells revealed that the constitutive overexpression of PP5 affords E(2)-dependent MCF-7 cells with the ability to proliferate in E(2)-depleted media. Together, these studies indicate that E(2)-induced PP5 expression functions to enhance E(2)-initiated signaling cascades leading to cell division and that aberrant PP5 expression may contribute to the development of MCF-7 cells with an estrogen-independent phenotype.

Maternal effects of the short integument mutation on embryo development in Arabidopsis

Maternal gene products deposited in an animal egg determine the polarity of embryonic axes and regulate embryonic cell-cell communication important for morphogenesis. Here we report the first maternal-effect embryo-defective mutation discovered in a plant. Recessive mutations in the SHORT INTEGUMENT (SIN1) gene in Arabidopsis were previously shown to influence ovule development and flowering time. Here we show that a sin1 mutation has a pronounced maternal effect on zygotic embryo development. A homozygous sin1 mutant embryo is normal when nursed by a sin1/+ heterozygous maternal sporophyte. Strikingly, a sin1 or a sin1/+ embryo that is nursed by a sin1 homozygous maternal sporophyte develops morphogenetic defects in the apical-basal and radial axes. The defects resemble those seen in some zygotic-effect embryonic pattern formation mutants. These results imply that in maternal cells the SIN1 gene either codes for or controls the production of a diffusible morphogen necessary for proper zygotic embryogenesis.

SHORT INTEGUMENT (SIN1), a gene required for ovule development in Arabidopsis, also controls flowering time

The short integument (sin1) mutation causes a female-specific infertility, and a defect in the control of time to flowering in Arabidopsis. Female sterility of Sin- plants is due to abnormal ovule integument development and aberrant differentiation of the megagametophyte in a subset of ovules. An additional defect of sin1 mutants is the production of an increased number of vegetative leaf and inflorescence primordia leading to delayed flowering. The delayed flowering phenotype of sin1-1 is not due to a defect in the perception of day length periodicity or in gibberellic acid metabolism. Phenotypes of double mutant combinations of sin1 with terminalflower (tfl1) indicate that SIN1 activity is required for precocious floral induction typical in a tfl1 mutant. Unexpectedly, sin1-1 tfl1-1 plants do not make pollen, thus revealing a novel role for TFL1 in the anther. Early flowers of sin1-1 ap1-1 double mutants are transformed to long inflorescence-like shoots. A genetic model for the role of SIN1 in flowering time control is proposed.

Orofacial dyskinesia in Down's syndrome

Of 54 patients aged 30-60 years with a diagnosis of Down's syndrome, 38 had evidence of orofacial dyskinesia, assessed using the AIMS. There was a strong relationship between the presence of such movements and the severity of mental handicap. No relationship was found between abnormal movements and age. None of the patients had previously taken neuroleptic medication.

Imaging Surface Atomic Structure by Means of Auger Electrons

Measurements of the complete angular distribution of Auger electrons emitted from well-defined platinum[111] single-crystal surfaces have led to the discovery that the distributions are composed of "silhouettes" of surface atoms "back lit" by emission from atoms deeper in the solid. Theoretical simulations of Auger electron angular distributions based upon atomic point emitters and spherical atomic scatterers of uniform cross section are in close agreement with these experimental results, but opposite to previous theoretical predictions. In view of the definitive results obtained and the straightforward agreement between theory and experiment, angular distribution Auger microscopy (ADAM) is useful for direct imaging of interfacial structure and investigation of electron-solid interactions in the physical and biological sciences and engineering. Applicability of ADAM is illustrated by images obtained for monolayers of silver and iodine on platinum[111].

Permselectivity and ion-exchange properties of Eastman-AQ polymers on glassy carbon electrodes

Eastman-AQ55D is a new poly(ester sulfonic acid) cation exchanger available in a commercial dissolved form. Films of this polymer were coated onto glassy carbon surfaces, and the resulting electrodes exhibit attractive permselectivity, ion-exchange, and antifouling properties. Substantial improvement in the selectivity is observed as a result of excluding anionic species from the surface. The charge-selective behavior is demonstrated in the presence of a variety of compounds of neurological significance. A rapid response to dynamic changes in the concentration of cationic and neutral species is observed. The polymer strongly binds multiply charged counterions. Cyclic voltammetry is used to determine the quantity of incorporated ions as a function of time, concentration, and other variables. The oxidation of hydrogen peroxide is catalyzed when Ru(bpy)3(2+) is incorporated in the coating. The film can also protect the substrate electrode from foulants present in the contacting solution. These features, as well as the low cost, simple coating procedure, strong adherence to surfaces, and versatility, make the Eastman-AQ55D polymer well-suited for a variety of electro-analytical applications.