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This collection showcases journal articles and other publications authored by faculty and researchers of the Department of Orthopedics and Physical Rehabilitation.

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Recently Published

  • High variability in patient reported outcome utilization following hip fracture: a potential barrier to value-based care

    Schraut, Nicholas; Bango, Jugert; Flaherty, Alexandra; Rossetti, Victoria; Swart, Eric (2021-12-22)
    For patients with hip fractures, outcomes can be measured by giving surveys measuring "patient rated outcome measures" (PROMs), performance based measures (PBMS), and objective medical outcomes (e.g., mortality, living situation, resource utilization). This study reviewed articles on hip fracture published in top academic journals, and found that most studies are not reliably using a single set of outcome measures including PROMs, and no single PROM or outcome battery is being used commonly. PURPOSE/INTRODUCTION: Osteoporotic hip fractures are associated with high levels of morbidity, mortality, and cost, while gains in mortality over the past 30 years have been modest. To improve care beyond simple mortality metrics requires identifying and then consistently measuring outcomes that are meaningful to patients and families. The purpose of this study was to review the top-tier hip fracture literature published in the past 30 years to determine if there are consensus outcome measures being routinely used and if the rate of reporting clinically meaningful patient-rated outcome measures is improving over time. METHODS: This was a systematic review and meta-analysis on outcome measures reported in osteoporotic hip fractures. Articles were included if they had been published over the last 30 years and were from high impact factor journals. Inclusion criteria were elderly hip fractures, therapeutic or prognostic study, unique and identifiable patients, and included follow-up beyond initial hospitalization. We analyzed study type, inclusion criteria, outcomes reported, and journal specialty orientation. RESULTS: Three hundred eighty-four articles were included in the final analysis. Sixty-seven percent of the articles were therapeutic studies; 33% were prognostic studies. The average number of patients in each study was 435; the average age was 78 years. The most commonly reported outcome was mortality, and was present in 79% of studies. There was a high degree of heterogeneity in patient-reported outcome measures, with the most popular score (Harris Hip Score) reported only 14% of the time. Only 6% of articles had all components of essential core outcome sets previously defined in the literature. CONCLUSIONS: Despite the apparent advances that have been made in our ability to care for hip fractures, the overall rate of reporting outcomes beyond mortality rate remains low. This lack of consensus represents a major barrier to implementation of value-based care in this patient population.
  • Accidental Prehabilitation: a case of increased exercise frequency before thoracic surgery

    Baima, Jennifer; Maxfield, Mark W.; Powers, Maggie; Varlotto, John M.; Uy, Karl (2020-03-08)
    Case Diagnosis: 67 year-old man was found down with dysarthria, dysphagia, and right lower limb weakness. He was diagnosed with left anterior cerebral artery ischemic stroke, acute renal failure, atrial fibrillation, and deep venous thrombosis. He remained hospitalized for months as he did not have insurance for inpatient rehabilitation care and could not be safely discharged home. Case Description: During that time, he got physical therapy 5 times per week and then 2 times per week. While hospitalized, he was subsequently diagnosed with left upper lobe nodule from T2aN0M0 lung adenocarcinoma. Physical therapy was increased back to 5 times per week for at least two weeks prior to left upper lobectomy and mediastinal lymphadenectomy by video-assisted thorascopic surgery 2.5 months after admission. Hospital course was complicated by anticoagulation and postoperative hemothorax, which responded to evacuation. He was discharged to subacute care after rate negotiation and then home. Discussions: We present the case of a patient who got physical therapy five times weekly in the 14 days prior to thoracic surgery. Although it is well established that exercise improves aerobic parameters and outcomes, the typical outpatient insurance benefit is under 120 minutes or only twice per week. 150 minutes a week is the current recommended amount of exercise for cancer patients. Since this patient could not be discharged due to lack of insurance for acute rehabilitation or outpatient care, he remained inpatient and received physical therapy five times weekly prior to surgery. Despite risk factors, he was safely discharged and recovered well. Conclusions: Our patient got a greater frequency and higher dose of exercise than most presurgical thoracic patients; this may be why he was able to tolerate thoracic surgery with multiple serious risk factors.
  • Don’t call me in the morning: why it might be best to see patients in-person, a case report

    Jarnagin, Johnny; Baima, Jennifer; Most, Mathew J.; Mazin, David A. (2020-03-07)
    Case Diagnosis: Post-irradiation Sarcoma Case Description: A 58-year-old woman with a history of stage IIIB squamous cell carcinoma of the cervix who was treated with chemoradiation, considered in remission 5 years prior on PET CT, and was under every 6-months surveillance for recurrence by gynecology. She presented to the Emergency Department for severe back pain, left sided sciatica, and paresthesias. In the absence of fracture or cord compression, she was discharged with recommendations for primary care follow-up. This took place over the telephone with referral to the spine center. One week later, her pain progressed to 10+/10 with dense left leg numbness, and multiple falls. Physiatry ordered a lumbar MRI for focal neurologic findings on exam, which revealed a large destructive lesion of the left ilium and left hemisacrum with soft tissue extension. This was later determined to be undifferentiated sarcoma, likely due to prior radiation. She is currently undergoing palliative chemotherapy. Discussions: Post-irradiation sarcomas (PIS) are a relatively rare event and exhibit dose dependency. Sarcomas can present with bone pain that can be worse at night and signs and symptoms of compression of surrounding structures. The pelvis is a common site for sarcoma development. Cases of PIS have presented in even just a few months post radiation therapy. The prognosis of patients with PIS is poorer than those with primary sarcomas. This patient would require hemipelvectomy to attempt curative treatment. Conclusions: PIS are typically aggressive, have poor prognosis, and can develop within months of high doses of radiation therapies; clinicians index of suspicion for sarcomas in patients with a history of radiation must be high. Evaluation for progressive pain, weakness, and numbness may not be amenable to telemedicine until technology improves. Patients that present with signs and symptoms of progressive nerve compression and bone pain should be re-examined early on.
  • The Role and Scope of Prehabilitation in Cancer Care

    Lukez, Alexander; Baima, Jennifer (2020-02-01)
    OBJECTIVES: To recognize cancer prehabilitation as a pretreatment regimen to increase functional status for patients requiring cancer treatment. This article presents current evidence addressing the efficacy and benefits of prehabilitation regimens in different cancer survivor populations. DATA SOURCES: Studies and case reports in the PubMed database. CONCLUSION: Cancer prehabilitation may improve outcomes. Prehabilitation may include targeted or whole-body exercise, nutrition, education, psychologic counseling, and smoking cessation. Opportunities exist to further improve access to and delivery of multimodal prehabilitation, and nurses play a critical role in connecting patients to these services. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses who are knowledgeable of cancer treatment-related effects are poised to assess survivors for existing impairments, advocate for prehabilitation for existing and potential morbidities, and monitor functional status over time. As patient educators, they are key to informing cancer survivors about the role of prehabilitation.
  • Micrococcal-Nuclease-Triggered On-Demand Release of Vancomycin from Intramedullary Implant Coating Eradicates Staphylococcus aureus Infection in Mouse Femoral Canals

    Ghimire, Ananta; Skelly, Jordan D.; Song, Jie (2019-12-26)
    Preventing orthopedic implant-associated bacterial infections remains a critical challenge. Current practices of physically blending high-dose antibiotics with bone cements is known for cytotoxicity while covalently tethering antibiotics to implant surfaces is ineffective in eradicating bacteria from the periprosthetic tissue environment due to the short-range bactericidal actions, which are limited to the implant surface. Here, we covalently functionalize poly(ethylene glycol) dimethacrylate hydrogel coatings with vancomycin via an oligonucleotide linker sensitive to Staphylococcus aureus (S. aureus) micrococcal nuclease (MN) (PEGDMA-Oligo-Vanco). This design enables the timely release of vancomycin in the presence of S. aureus to kill the bacteria both on the implant surface and within the periprosthetic tissue environment. Ti6Al4V intramedullary (IM) pins surface-tethered with dopamine methacrylamide (DopaMA) and uniformly coated with PEGDMA-Oligo-Vanco effectively prevented periprosthetic infections in mouse femoral canals inoculated with bioluminescent S. aureus. Longitudinal bioluminescence monitoring, muCT quantification of femoral bone changes, end point quantification of implant surface bacteria, and histological detection of S. aureus in the periprosthetic tissue environment confirmed rapid and sustained bacterial clearance by the PEGDMA-Oligo-Vanco coating. The observed eradication of bacteria was in stark contrast with the significant bacterial colonization on implants and osteomyelitis development found in the absence of the MN-sensitive bactericidal coating. The effective vancomycin tethering dose presented in this on-demand release strategy was > 200 times lower than the typical prophylactic antibiotic contents used in bone cements and may be applied to medical implants and bone/dental cements to prevent periprosthetic infections in high-risk clinical scenarios. This study also supports the timely bactericidal action by MN-triggered release of antibiotics as an effective prophylactic method to bypass the notoriously harder to treat periprosthetic biofilms and osteomyelitis.
  • Prehabilitation for patient positioning: pelvic exercises assist in minimizing inter-fraction sacral slope variability during radiation therapy

    O'Loughlin, Lauren; Lukez, Alexander; Ma, Yunsheng; Baima, Jennifer; Moni, Janaki (2019-11-12)
    Reproducible patient positioning is essential for precision in radiation therapy (RT) delivery. We tested the hypothesis that a structured daily pre-treatment stretching regimen is both feasible and effective for minimizing variability in positioning, as measured by sacral slope angles (SSA). Eight female subjects undergoing pelvic radiotherapy performed a structured daily hip exercise regimen (extension and external rotation) immediately prior to both simulation imaging and daily treatment, throughout their RT course. This exercising cohort was compared to a retrospective review of 20 subjects (17 women and 3 men) undergoing RT, who had usual care. SSA measurements from daily pre-treatment imaging were compared to SSA measurements from the simulation CT. The average variation in SSA among the intervention subjects was 0.91 degrees (+/- 0.58 degrees ), with a range among subjects of 0.57 degrees -1.27 degrees . The average variation for the control subjects was 2.27 degrees (+/- 1.43 degrees ), ranging 1.22 degrees -5.09 degrees . The difference between the two groups was statistically significant (p = 0.0001). There was a statistically significant SSA variation between groups at each week of treatment. There was no significant variation among the intervention subjects between week 1 and later weeks, whereas subjects in the control group demonstrated significant SSA variation between week 1 and later weeks. We demonstrated a significant decrease in the variability of SSA by implementing a simple pre-treatment exercise program, while control subjects exhibited increasing variation in SSA over the course of treatment. We conclude that there is a potential benefit of prehabilitation during pelvic RT; however, a larger randomized control trial is required to confirm the findings.Clinical Trial: This research project was approved by the University of Massachusetts Medical School IRB (IRB ID H00012353) on January 21, 2017. The study is listed on ClinicalTrials.gov, provided by the U.S. National Library of Medicine, found with identifier NCT03242538.
  • Can we predict failure of percutaneous fixation of femoral neck fractures

    Kane, Christina; Jo, Jacob; Siegel, Jodi; Matuszewski, Paul E.; Swart, Eric F. (2019-10-22)
    PURPOSE: This study evaluated a series of geriatric femoral neck fracture treated with closed reduction percutaneous pinning (CRPP) at a single level-1 trauma center to determine if there are any simple, reliable, radiographic characteristics that can be used to predict increased risk of post-operative failure in nondisplaced and valgus impacted fracture patterns. METHODS: We conducted a retrospective cohort study of all patients with femoral neck fractures (AO/OTA 31B) who underwent CRPP over a 12-year period at a single Level 1 trauma center. Failure was defined as radiographic failure within the first year after the index operation requiring revision surgery. Common patterns identified on initial review were the presence of a visible medial transcervical line (MTL) felt to indicate a tension-sided failure, a straight inferior calcar (SIC) indicating severe valgus impaction, and quality of intra-operative screw positioning. X-rays of patients were then reviewed for these characteristics in a blinded manner by three different trauma-fellowship trained orthopedic surgeons. Inter-rater reliability was calculated using Fleiss' Kappa Coefficient. Comparisons of failure rates between groups were made using a Fisher's Exact test. RESULTS: 139 patients who underwent CRPP for a femoral neck fracture and follow-up for at least 90 days were identified and reviewed. There were a total of 19 failures (13.6%) within one year. The patients with a varus fracture had a failure rate of 9/24 (37.5%). Of the valgus/nondisplaced fractures, MTL was identified in 42/115 (36%) patients. Inter-rater agreement was high for the presence of an MTL (84%, Kappa 0.69). Patients with an MTL had a fourfold increase in risk of failure (7/42=17% with an MTL vs. 3/73=4% without, p 0.03). The presence of a SIC and quality of screw placement were not predictive of failure. CONCLUSION: Varus femoral neck fractures fixed with CRPP have a high rate of failure (37.5%). Nondisplaced or valgus impacted fractures with the presence of a visible medial transcervical line on pre-operative radiographic imaging resulted in a fourfold increase in the risk of failure after CRPP. Identification of the MTL will help treating surgeons better council patients when making pre-operative decisions between arthroplasty and CRPP.
  • Early radiographic failure of reverse total shoulder arthroplasty with structural bone graft for glenoid bone loss

    Ho, Jason C.; Thakar, Ocean; Chan, Wayne W.; Nicholson, Thema; Williams, Gerald R.; Namdari, Surena (2019-10-11)
    INTRODUCTION: Structural glenoid bone grafting in reverse total shoulder arthroplasty (RSA) has previously been reported to have good functional outcomes and low complication rates. We have observed different complication rates and hypothesized that baseplate fixation and severity of deformity may be predictors of early failure. METHODS: We retrospectively identified 44 patients who underwent RSA with structural bone grafting for glenoid bone defects. All patients had preoperative and postoperative (Grashey and axillary) radiographs at a minimum of 1 year after surgery and within 3 months of surgery for evaluation of implant and graft positioning. Clinical data and outcome scores were collected at the same intervals. RESULTS: There were 61% females and 39% males, with an average age of 74 +/- 8 years at the time of surgery. The median final radiographic follow-up was 20 months, with 37 primary RSA and 7 revision RSA. Graft resorption was found in 11 of 44 patients (25%), and radiographic failure was found in 11 of 44 patients (25%) at a median of 8 months (range 3-51 months). Forward elevation, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Single Assessment Numeric Evaluation (SANE), and Simple Shoulder Test (SST) scores all significantly improved postoperatively (P < .0001). Radiographic baseplate failure was associated with graft resorption (P = .002), more retroversion correction (P = .02), and worse SANE scores at final follow-up (P = .01). DISCUSSION/CONCLUSION: RSA with structural bone graft improved range of motion and function, but there was a larger than previously reported baseplate loosening rate. This early radiographic loosening appeared to be associated with graft resorption, retroversion correction, and worse outcome scores.
  • Self-measured wrist range of motion by wrist-injured and wrist-healthy study participants using a built-in iPhone feature as compared with a universal goniometer

    Modest, Jacob; Clair, Brian; DeMasi, Robin; Meulenaere, Stacy; Howley, Anthony; Aubin, Michelle E.; Jones, Marci D. (2019-10-01)
    STUDY DESIGN: Cross-sectional cohort. INTRODUCTION: Smartphone gyroscope and goniometer applications have been shown to be a reliable way to measure wrist ROM when used by researchers or trained staff. If wrist-injured patients could reliably measure their own ROM, rehabilitation efforts could be more effectively tailored. PURPOSE OF THE STUDY: To assess agreement of self-measured ROM by wrist-injured and wrist-healthy study participants using a built-in iPhone 5 level feature as compared to researcher-measured ROM using a universal goniometer (UG). METHODS: Thirty wrist-healthy and 30 wrist-injured subjects self-measured wrist flexion, extension, supination, and pronation ROM using the built-in preinstalled digital level feature on an iPhone 5. Simultaneously a researcher measured ROM with a UG. RESULTS: Average absolute deviation between the self-measured iPhone 5 level feature and researcher-measured UG ROM was less than 2 degrees for all 4 movements individually and combined was found to be 1.6 degrees for both populations. Intraclass correlation coefficient showed high correlation with values over 0.94 and Bland-Altman plots showed very strong agreement. There was no statistical difference in the ability of wrist-injured and healthy patients to self-measure wrist ROM. DISCUSSION: Both populations showed very high agreement between their self-measured ROM using the built-in level feature on an iPhone 5 and the researcher-measured ROM using the UG. Both populations were able to use the iPhone self-measurement equally well and the injury status of the subject did not affect the agreement results. CONCLUSION: Wrist-healthy and wrist-injured subjects were able to reliably and independently measure ROM using a smartphone level feature. reserved.
  • "Found Down" Compartment Syndrome: Experience from the Front Lines of the Opioid Epidemic

    Parzych, Lydia; Jo, Jacob; Diwan, Amna; Swart, Eric F. (2019-09-04)
    BACKGROUND: With the worsening of the opioid epidemic, there has been an increasing number of cases in which patients are "found down" following a drug overdose and develop a crush injury resulting in muscle necrosis, rhabdomyolysis, and elevated compartment pressures in a unique presentation of compartment syndrome. The purpose of the present study is to summarize our experience at a trauma center in a region with a high endemic rate of opiate abuse to provide guidance for the management of patients with "found down" compartment syndrome. METHODS: We performed a retrospective review of the records of patients who had been found unconscious as the result of overdose, with findings that were concerning for compartment syndrome, and had been managed with fasciotomy or observation at the discretion of the surgeon. The patients were divided into 3 groups based on presentation (partial deficits, complete deficits, or unexaminable), and the operative findings, hospital course, laboratory values, and functional status were compared between the groups. RESULTS: Over 12 years, we identified 30 "found down" patients who had an examination that was concerning for compartment syndrome. Twenty-five patients were managed with fasciotomy; this group required an average of 4.2 operations and had a 20% infection rate and a 12% amputation rate. Lactate, creatine phosphokinase, and creatinine levels typically were elevated but did not correspond with muscle viability or return of function. At the time of initial debridement, 56% of patients had muscle that appeared nonviable, although muscle function returned in 28% of the patients who had questionable viability. Four patients had no motor or neurological function on initial examination, and none had meaningful return of function at the time of the latest follow-up. Of the 10 patients who had partial neurological deficits at the time of presentation and underwent fasciotomy, over half (70%) had some improvement in ultimate function. CONCLUSIONS: Patients who are "found down" following an opiate overdose with crush injuries resulting in compartment syndrome have a high surgical complication rate and poor recovery of function. The limited data from the present study suggest that those with absent function at the time of presentation are unlikely to gain function after fasciotomy, and the risk-benefit ratio of fasciotomy in this patient population may be different from that for patients with traumatic compartment syndrome. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
  • Significant Suppression of Staphylococcus aureus Colonization on Intramedullary Ti6Al4V Implants Surface-Grafted with Vancomycin-Bearing Polymer Brushes

    Zhang, Ben; Braun, Benjamin M.; Skelly, Jordan D.; Ayers, David C.; Song, Jie (2019-08-14)
    Orthopedic implant-associated bacterial infection presents a major health threat due to tendency for periprosthetic bacterial colonization/biofilm formation that protects bacteria from host immune response and conventional antibiotic treatment. Using surface-initiated atom transfer radical polymerization and copper-catalyzed azide-alkyne cycloaddition (CuAAC), alkynylated vancomycin is conjugated to azido-functionalized side chains of polymethacrylates grafted from Ti6Al4V. High-efficiency CuAAC across the substrate is confirmed by complete surface conversion of azides by X-ray photoelectron spectroscopy (XPS) and elemental mapping of changing characteristic elements. The vancomycin-modified surface (Ti-pVAN) significantly reduces in vitro adhesion and colonization of Staphylococcus aureus (S. aureus), a main bacterial pathogen responsible for periprosthetic infection and osteomyelitis, compared to untreated Ti6Al4V, supporting retained antibacterial properties of the covalently conjugated antibiotics. When the surface-modified intramedullary Ti-pVAN pins are inserted into mouse femoral canals infected by bioluminescent Xen29 S. aureus, significantly reduced local bioluminescence along with mitigated blood markers for infection are detected compared to untreated Ti6Al4V pins over 21 days. Ti-pVAN pins retrieved after 21 days are confirmed with approximately 20-fold reduction in adherent bacteria counts compared to untreated control, supporting the ability of surface-conjugated vancomycin in inhibiting periprosthetic S. aureus adhesion and colonization.
  • Multifunctional scaffolds for facile implantation, spontaneous fixation, and accelerated long bone regeneration in rodents

    Zhang, Ben; Skelly, Jordan D.; Maalouf, Jacob R.; Ayers, David C.; Song, Jie (2019-07-24)
    Graft-guided regenerative repair of critical long bone defects achieving facile surgical delivery, stable graft fixation, and timely restoration of biomechanical integrity without excessive biotherapeutics remains challenging. Here, we engineered hydration-induced swelling/stiffening and thermal-responsive shape-memory properties into scalable, three-dimensional-printed amphiphilic degradable polymer-osteoconductive mineral composites as macroporous, non-load-bearing, resorbable synthetic grafts. The distinct physical properties of the grafts enabled straightforward surgical insertion into critical-size rat femoral segmental defects. Grafts rapidly recovered their precompressed shape, stiffening and swelling upon warm saline rinse to result in 100% stable graft fixation. The osteoconductive macroporous grafts guided bone formation throughout the defect as early as 4 weeks after implantation; new bone remodeling correlated with rates of scaffold composition-dependent degradation. A single dose of 400-ng recombinant human bone morphogenetic protein-2/7 heterodimer delivered via the graft accelerated bone regeneration bridging throughout the entire defect by 4 weeks after delivery. Full restoration of torsional integrity and complete scaffold resorption were achieved by 12 to 16 weeks after surgery. This biomaterial platform enables personalized bone regeneration with improved surgical handling, in vivo efficacy and safety.
  • Venous Thromboembolism Prophylaxis for Patients Having Elective Spine Surgery: When, Why, and How Much

    Rockson, Hayden B.; DiPaola, Christian P.; Connolly, Patrick J.; Stauff, Michael P. (2019-07-03)
    The prevalence of venous thromboembolism (VTE) events varies widely following elective spine surgery, with reported rates ranging from 0.21% to 13.6%. Risk factors for the development of VTE after spine surgery include patient or family history, obesity, longer operative time, manipulation of the great vessels, and decreased mobility postoperatively. There is limited consensus regarding the selection and initiation of postoperative chemoprophylaxis, which should be implemented thoughtfully because of the bleeding risk and, specifically, the development of epidural hematoma. Prophylactic use of inferior vena cava filters in low-risk patients having elective spine surgery has not been well supported in the literature. Further investigation is needed to determine its utility as an additional modality to prevent postoperative pulmonary embolus in elective spine surgery.
  • Sarcopenia in lung cancer: Could chest imaging help?

    Baima, Jennifer; Schipani, Elke Sarah; Kamran, Wasih; Varlotto, John M.; McIntosh, Lacey J.; Uy, Karl; Emmerick, Isabel; Most, Mathew J. (2019-07-02)
    Introduction: Fifteen to seventy percent of cancer patients demonstrate sarcopenia.1-6,[i],[ii],[iii],[iv],[v],[vi],[vii],[viii],[ix],[x],[xi],[xii],[xiii] Analysis of iliopsoas cross-sectional area, a non-invasive surrogate measure for sarcopenia in patients with cancer has been associated with survival.[xiv],[xv],[xvi],[xvii] The pectoralis muscle may be a more accessible target for measuring sarcopenia in lung cancer patients,[xviii] but it is not known if it this correlates with iliopsoas cross-sectional area. Since measurements vary, it is most accurate to use internal controls. We attempted to examine the cross-sectional area of the two muscles and any change over the treatment period. Methods: Charts were reviewed in 44 subjects who underwent surgical treatment of lung cancer. Available imaging at pre-treatment, 6 months, and 12 months was reviewed for the cross-sectional area of the pectoralis and the iliopsoas. The cross-sectional area of the pectoralis and the iliopsoas were measured manually at diagnosis by two different researchers, and the pectoralis was measured at 6 months and 12 months in subjects who were treated for lung cancer. Follow-up iliopsoas data was not available. Results: Of the 44 subjects, 13 had a complete set of imaging. The mean age was 66 years old and the mean BMI was 28.72. There were 8 females and 5 males. 12 out of 13 were Caucasian. 12 out of 13 were stage T1 or T2. 12 out of 13 had undergone lobectomy. 10 out of the 13 were at ECOG performance status grade 0 at diagnosis. 4 out of 13 had postoperative events. The mean iliopsoas area at diagnosis was 8.17cm2. The mean pectoralis area at diagnosis was 14.5 cm2. The mean pectoralis area at 6 months was 13.9 cm2. The mean pectoralis area at 12 months was 14.5cm2. 8 out of 13 subjects had a decrease in mean pectoralis area at 6 months and 6 subjects had a decrease at 12 months. Conclusion: There was no significant decrease in cross-sectional area of the pectoralis over the lung cancer treatment period. This could be because of the initial high performance status of our sample, the small size, or sarcopenia occurs comorbidly with presentation. References: [i] Bowden JC, Williams LJ, Simms A, Price A, Campbell S, Fallon MT, Fearon KC. Prediction of 90 day and overall survival after chemoradiotherapy for lung cancer: role of performance status and body composition. Clinical Oncology. 2017 Sep 1;29(9):576-84. [ii] Kim EY, Lee HY, Kim KW, Lee JI, Kim YS, Choi WJ, Kim JH. Preoperative Computed Tomography–Determined Sarcopenia and Postoperative Outcome after Surgery for Non-Small Cell Lung Cancer. Scandinavian Journal of Surgery. 2017 Dec 1:1457496917748221. [iii] Amini N, Spolverato G, Gupta R, Margonis GA, Kim Y, Wagner D, Rezaee N, Weiss MJ, Wolfgang CL, Makary MM, Kamel IR. Impact total psoas volume on short-and long-term outcomes in patients undergoing curative resection for pancreatic adenocarcinoma: a new tool to assess sarcopenia. Journal of Gastrointestinal Surgery. 2015 Sep 1;19(9):1593-602. [iv] Kasatkina E. CT-assessment of sarcopenia as a predictor of post-Whipple complications. European Congress of Radiology 2013. [v] Sabel MS, Lee J, Cai S, Englesbe MJ, Holcombe S, Wang S. Sarcopenia as a prognostic factor among patients with stage III melanoma. Annals of surgical oncology. 2011 Dec 1;18(13):3579-85. [vi] Blauwhoff-Buskermolen S, Versteeg KS, de van der Schueren MA, den Braver NR, Berkhof J, Langius JA, Verheul HM. Loss of muscle mass during chemotherapy is predictive for poor survival of patients with metastatic colorectal cancer. Journal of Clinical Oncology. 2016 Feb 22;34(12):1339-44. [vii] Villaseñor A, Ballard-Barbash R, Baumgartner K, Baumgartner R, Bernstein L, McTiernan A, Neuhouser ML. Prevalence and prognostic effect of sarcopenia in breast cancer survivors: the HEAL Study. Journal of Cancer Survivorship. 2012 Dec 1;6(4):398-406. [viii] Kuroki LM, Mangano M, Allsworth JE, Menias CO, Massad LS, Powell MA, Mutch DG, Thaker PH. Pre-operative assessment of muscle mass to predict surgical complications and prognosis in patients with endometrial cancer. Annals of surgical oncology. 2015 Mar 1;22(3):972-9. [ix] Peng PD, Van Vledder MG, Tsai S, De Jong MC, Makary M, Ng J, Edil BH, Wolfgang CL, Schulick RD, Choti MA, Kamel I. Sarcopenia negatively impacts short‐term outcomes in patients undergoing hepatic resection for colorectal liver metastasis. Hpb. 2011 Jul 1;13(7):439-46. [x] Prado CM, Baracos VE, McCargar LJ, Reiman T, Mourtzakis M, Tonkin K, Mackey JR, Koski S, Pituskin E, Sawyer MB. Sarcopenia as a determinant of chemotherapy toxicity and time to tumor progression in metastatic breast cancer patients receiving capecitabine treatment. Clinical cancer research. 2009 Apr 15;15(8):2920-6. [xi] Reisinger KW, Bosmans JW, Uittenbogaart M, Alsoumali A, Poeze M, Sosef MN, Derikx JP. Loss of skeletal muscle mass during neoadjuvant chemoradiotherapy predicts postoperative mortality in esophageal cancer surgery. Annals of surgical oncology. 2015 Dec 1;22(13):4445-52. [xii] Cushen SJ, Power DG, Murphy KP, McDermott R, Griffin BT, Lim M, Daly L, MacEneaney P, O'Sullivan K, Prado CM, Ryan AM. Impact of body composition parameters on clinical outcomes in patients with metastatic castrate-resistant prostate cancer treated with docetaxel. Clinical nutrition ESPEN. 2016 Jun 1;13:e39-45. [xiii] van Vugt JL, Braam HJ, van Oudheusden TR, Vestering A, Bollen TL, Wiezer MJ, de Hingh IH, van Ramshorst B, Boerma D. Skeletal muscle depletion is associated with severe postoperative complications in patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis of colorectal cancer. Annals of surgical oncology. 2015 Oct 1;22(11):3625-31. [xiv] Feliciano EM, Kroenke CH, Meyerhardt JA, Prado CM, Bradshaw PT, Kwan ML, Xiao J, Alexeeff S, Corley D, Weltzien E, Castillo AL. Association of Systemic Inflammation and Sarcopenia With Survival in Nonmetastatic Colorectal Cancer: Results From the C Scans Study. JAMA oncology. 2017 Dec 1;3(12):e172319-. [xv] Prado CM, Lieffers JR, McCargar LJ, Reiman T, Sawyer MB, Martin L, Baracos VE. Prevalence and clinical implications of sarcopenic obesity in patients with solid tumours of the respiratory and gastrointestinal tracts: a population-based study. The lancet oncology. 2008 Jul 1;9(7):629-35. [xvi] Peng P, Hyder O, Firoozmand A, Kneuertz P, Schulick RD, Huang D, Makary M, Hirose K, Edil B, Choti MA, Herman J. Impact of sarcopenia on outcomes following resection of pancreatic adenocarcinoma. Journal of gastrointestinal surgery. 2012 Aug 1;16(8):1478-86. [xvii] Tan BH, Birdsell LA, Martin L, Baracos VE, Fearon KC. Sarcopenia in an overweight or obese patient is an adverse prognostic factor in pancreatic cancer. Clinical cancer research. 2009 Nov 15;15(22):6973-9. [xviii] Go SI, Park MJ, Song HN, Kang MH, Park HJ, Jeon KN, Kim SH, Kim MJ, Kang JH, Lee GW. Sarcopenia and inflammation are independent predictors of survival in male patients newly diagnosed with small cell lung cancer. Supportive Care in Cancer. 2016 May 1;24(5):2075-84.
  • Pelvic prehabilitation: pelvic exercises assist in minimizing inter-fraction sacral slope variability during radiation therapy

    Baima, Jennifer; O'Loughlin, Lauren; Lukez, Alexander; Ma, Yunsheng; Moni, Janaki (2019-07-02)
    Introduction: Prehabilitation for radiation therapy is not well studied. Retrospective data shows variability in set-up positioning of patients during daily pelvic RT. We hypothesize that a brief structured daily exercise regimen is feasible for subjects to perform before RT and may minimize variability in positioning as measured by sacral slope angles (SSA) on lateral views. Determining feasibility and effectiveness of these exercises in decreasing set-up variability has clinical implications, both for targeting treatment sites and preventing adverse effects. Methods: Subjects in the exercise intervention condition (n=8, 8 F) performed a structured daily hip exercise regimen throughout the duration of RT, and subjects in the historical control condition (n=20, 17 F, 3 M) had usual care. For each patient, SSA measurements were compared to SSA measurements from the simulation CT for 5 weeks during RT. The extent of variability of measurements between two conditions was studied using a linear mixed model. For all patients in both conditions, the same two readers independently measured SSA to compare angles on day of simulation against the angles measured from each day of RT. Results: The average variation in SSA for intervention condition was 0.913° (±0.582°), with range among patients 0.57°-1.3°. The average variation for control condition was 2.27° (±1.43°), with range among patients 1.22° - 5.09°. The difference between two conditions was statistically significant (p=0.0019). Comparison of SSA variation between conditions demonstrated a statistically significant difference at each week (wk 1: p = 0.0071, wk 2: p = 0.0077, wk 3: p = 0.011, wk 4: p = 0.005, wk 5: p = 0.0079). The exercise intervention condition had no significant variation between week 1 and later weeks (wk 2: p = 0.876, wk 3: p = 0.741, wk 4: p = 0.971, wk 5: p = 0.397). The control condition showed greater SSA variation between week 1 and later weeks (wk 2: p = 0.868, wk 3: p = 0.915, wk 4: p = 0.015, wk 5: p = 0.224), with significant variation between weeks 1 and 4. No subject reported any adverse effects. Conclusion: We observed a significant decrease in sacral slope variability in our exercise cohort as compared to historical controls. SSA variation for control condition increased over the course of treatment with significant difference noted between week 1 and 4. A larger clinical trial is required to evaluate the potential clinical benefits of a structured daily exercise regimen during pelvic RT. References: Silver JK, Baima J. Cancer prehabilitation: an opportunity to decrease treatment-related morbidity, increase cancer treatment options, and improve physical and psychological health outcomes. American journal of physical medicine & rehabilitation. 2013 Aug 1;92(8):715-27. Lukez A, O’Loughlin L, Bodla M, Baima J, Moni J. Positioning of port films for radiation: variability is present. Medical Oncology. 2018 May 1;35(5):77. Kwon JW, Huh SJ, Yoon YC, Choi SH, Jung JY, Oh D, Choe BK. Pelvic bone complications after radiation therapy of uterine cervical cancer: evaluation with MRI. American Journal of Roentgenology. 2008 Oct;191(4):987-94. Stubblefield MD. Radiation fibrosis syndrome: neuromuscular and musculoskeletal complications in cancer survivors. PM&R. 2011 Nov 1;3(11):1041-54.
  • Orthopaedic Faculty and Resident Sex Diversity Are Associated with the Orthopaedic Residency Application Rate of Female Medical Students

    Okike, Kanu; Phillips, Donna P.; Swart, Eric F.; O'Connor, Mary I. (2019-06-19)
    BACKGROUND: The representation of women in orthopaedics in the United States remains among the lowest in all fields of medicine, and prior research has suggested that this underrepresentation may stem from lower levels of interest among female medical students. Of the many proposed reasons for this lack of interest, the male-dominated nature of the field is one of the most commonly cited. The purpose of this study was to determine the degree to which the representation of women among orthopaedic faculty and residents influences female medical students at that institution to apply for a residency in orthopaedics. METHODS: Using data provided by the Association of American Medical Colleges, we identified all U.S. medical schools that were affiliated with an orthopaedic surgery department and an orthopaedic surgery residency program (n = 107). For each institution, data on the representation of women among the orthopaedic faculty and residents from 2014 through 2016 were collected, as well as data on the proportion of female medical school graduates who applied to an orthopaedic residency program from 2015 through 2017. The association between institutional factors and the female medical student orthopaedic application rate was assessed. RESULTS: Of 22,707 women who graduated from medical school during the 3-year study period, 449 (1.98%) applied to an orthopaedic surgery residency program. Women who attended medical school at institutions with high orthopaedic faculty sex diversity were more likely to apply for a residency in orthopaedics (odds ratio [OR], 1.30; 95% confidence interval [CI], 1.04 to 1.64; p = 0.023), as were women who attended medical school at institutions with high orthopaedic resident sex diversity (OR, 1.30; 95% CI, 1.05 to 1.61; p = 0.019). CONCLUSIONS: In this study, we found that increased sex diversity among orthopaedic faculty and residents was associated with a greater likelihood that female medical students at that institution would apply for an orthopaedic residency. These results suggest that at least some of the factors currently impeding female medical student interest in orthopaedics may be modifiable. These findings may have important implications for efforts to improve the sex diversity of the field of orthopaedics going forward.
  • Competency-Based Curriculum Development to Meet the Needs of People With Disabilities: A Call to Action

    Ankam, Nethra S.; Bosques, Glendaliz; Sauter, Carley; Stiens, Steven; Therattil, Maya; Williams, Faren H.; Atkins, Caleb C.; Mayer, R. Samuel (2019-06-01)
    People with disabilities constitute 22.2% of the population in the United States, and virtually all physicians have people with disabilities in their clinical practice across a wide range of diagnostic groups. However, studies demonstrate that people with disabilities are inadequately served by the health care system, leading to high costs and poor outcomes. The authors argue that one cause of this discrepancy is that medical students receive limited training in the care of people with disabilities and may therefore not be able to adequately meet the competencies that underlie the Core Entrustable Professional Activities for Entering Residency. To address these gaps, the authors present practical examples of integrating concepts of disability into the curriculum with minimal additional time requirements. A comprehensive disability curriculum is suggested to include active classroom learning, clinical, and community-based experiences. At institutions that do not have a comprehensive curriculum, the authors recommend adding disability-related knowledge and skill acquisition to existing curricula through modifications to current case-based learning, simulated patients, and objective structured clinical examinations. To facilitate curriculum development, they recommend that the World Health Organization International Classification of Functioning, Disability, and Health be used as a tool to build disability concepts into active learning. The goal of these recommended curricular changes is to enhance student performance in the clinical management of people with disabilities and to better train all future physicians in the care of this population.
  • Can the use of femoral notch view alone decrease measurement error of distal interlocking screws after retrograde femoral nailing

    Liu, Boshen; Zuelzer, David A.; Allen, Jerad; Comadoll, Shea; Hsu, Joseph R.; Swart, Eric F.; Matuszewski, Paul E. (2019-04-01)
    OBJECTIVES: Determine if using different fluoroscopic views of the knee (Notch or Tangential) improves accuracy of screw lengths assessment compared to the standard posteroanterior (PA). PARTICIPANTS AND METHODS: Orthopaedic surgeons at three ACGME-accredited residency programs were asked via survey to assess screw lengths on PA, femoral notch, and tangential radiographic views. RESULTS: Responders correctly identified screw length using PA, femoral notch, and medial tangential views at rates of 46.75%, 52.27%, and 44.37% respectively. Respondents detected overall screw length discrepancies most accurately using the femoral notch view (Odds Ratio 1.26; 95% confidence interval: 1.07-1.47; P < 0.005). There was no statistical difference between the residents and faculty cohort in ability to detect screw length discrepancy. CONCLUSION: Differentiating distal interlocking screw lengths on traditional imaging (AP/Notch/Tangential) is poor. The femoral notch view significantly improves accuracy in radiographic determination of screw length. The femoral notch view should be used in conjunction with the traditional PA view to maximize sensitivity and specificity for detecting prominent screws.
  • No Woman is an Island -- Access to Care and Extreme Measures for Cancer Pain and Lymphedema: A Case Report

    Hall, Lauren M.; Reilly, Julia; Most, Mathew J.; Baima, Jennifer (2019-02-22)
    Background: Cancer rehabilitation is a rapidly growing diverse field in physiatry. This case provides an example where rehabilitation physiatrists played a crucial role in the pain management, education, and rehabilitation before and after a palliative amputation. Due to her limited resources, both in her home country and in her local community, she could not access appropriate care that may have prevented the need for amputation. Though amputation is not generally accepted as the first line of treatment for pain, there have been several reports of palliative amputation in metastatic cancer patients. In particular, fore quarter amputations have been reported in metastatic breast cancer patients to manage pain and recurrent fractures.
  • Diabetic neuropathic foot without neuropathy: Could it be cancer? - a case report

    Baima, Jennifer; Santiago, Felix; Most, Mathew J. (2019-02-21)
    We present a case of a 64 year-old diabetic male who presented with months of progressively worsening foot pain and swelling, who was initially diagnosed with Charcot joint disease.(CJD) He was ultimately found to have a very rare tumor.

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