Search

Total hip arthroplasty (THA) patients often receive routine radiographs in the year following their index surgery. This study sought to investigate the clinical and economic value of obtaining routine postoperative hip radiographs for asymptomatic patients following primary elective THA.A retrospective cohort study of consecutive patients who underwent primary elective THA from 2016 to 2019 was conducted. Patients undergoing nonelective or revision THA, radiographic follow-up10 months, and patients aged18 years were excluded. All radiographs were reviewed for abnormalities in the first postoperative year by an arthroplasty fellowship-trained orthopaedic surgeon, blinded to the symptoms of the patient.Of the 327 patients (351 hips) included, 57.2% were women and 68.2% were White, with an average age of 65 years (range, 22-97 years) and average body mass index of 29.1 kg/mRoutine postoperative radiographs may be of limited utility in the asymptomatic patient in the first year following elective primary THA. Consideration should be given to limit postoperative radiographs following standard elective THA, while reserving postoperative radiographic evaluation for patients who are symptomatic.Level III.

Health equity requires allocation of resources to eliminate the systematic disparities in health, imposed on marginalized groups, which adversely impact outcomes. A socioecological approach is implemented to elucidate the role of health equity research and policy for underrepresented minority and socioeconomically disadvantaged populations. Through investigation of the individual, community, institution, and public policy, we investigate problems and propose solutions to ensure fair and just treatment of all patients requiring hand surgery.

PURPOSE: Patients with severe ulnar neuropathy at the elbow frequently experience suboptimal surgical outcomes. Clinical symptoms alone may not accurately represent the severity of underlying nerve injury, calling for objective assessment tools, such as electrodiagnostic studies. The goal of our study was to determine whether specific electrodiagnostic parameters can be used to predict outcomes after in situ decompression of the ulnar nerve. METHODS: This prospective study enrolled consecutive patients 18 years of age or older with a diagnosis of ulnar neuropathy at the elbow. Patients completed a baseline battery of motor, sensory, functional and electrodiagnostic tests prior to undergoing in situ decompression of the ulnar nerve and were re-assessed at 6 weeks, 3 months, 6 months, and 12 months post-operatively. Forty-two patients completed at least two follow-up assessments and were included in the study. RESULTS: When controlling for other electrodiagnostic measurements and demographic factors, none of the electrodiagnostic parameters were predictive of outcomes at 12 months post-operatively. Patients with decreased CMAP amplitudes demonstrated slower trends of recovery in grip strength, pinch strength, and overall score on the Michigan Hand Questionnaire (MHQ) as well as its function, work and activities of daily living subscales, Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) and Carpal Tunnel Questionnaire (CTQ) scores. Decreased motor nerve conduction velocity (NCV) was predictive of slower recovery of 2-point discrimination and pinch strength. CONCLUSIONS: CMAP amplitude, but not other conventional electrodiagnostic parameters, was predictive of functional outcomes after in situ decompression of the ulnar nerve. This parameter should play a role in determining the timing and prognosis of treatment for ulnar neuropathy at the elbow. LEVEL OF EVIDENCE: Level II prognostic

We evaluated pembrolizumab monotherapy in patients with advanced salivary gland carcinoma on the phase 2 KEYNOTE-158 study (NCT02628067).Eligible patients had histologically/cytologically confirmed advanced salivary gland carcinoma with prior failure or intolerance to standard therapy, measurable disease per Response Evaluation Criteria in Solid Tumours (RECIST) v1.1., and ECOG performance status 0-1. Patients were enrolled irrespective of tumour PD-L1 expression. Patients received pembrolizumab 200 mg Q3W for up to 35 cycles (∼2 years). Radiographic imaging occurred every 9 weeks through month 12, then every 12 weeks. PD-L1 positivity was defined as combined positive score ≥1 (evaluated using PD-L1 IHC 22C3 pharmDx). The primary endpoint was objective response rate per RECIST v1.1.In total, 109 patients were enrolled (PD-L1-positive, 25.7%). At the data cutoff (October 5, 2020), median follow-up was 53.3 (range, 50.8-56.3) months. Objective response rate was 4.6% (95% CI, 1.5-10.4%) among all patients (complete response, n = 1; partial response, n = 4) and was 10.7% (95% CI, 2.3-28.2%) in patients with PD-L1-positive disease and 2.6% (95% CI, 0.3-9.1%) in patients with PD-L1-negative disease. Duration of response was ≥24 months for all 5 responders; median duration of response was not reached (range, 25.1-49.8+ months). Median progression-free survival and overall survival were 4.0 (95% CI, 2.6-4.2) and 21.1 (95% CI, 15.9-25.5) months, respectively. Treatment-related adverse events occurred in 75.2% (grade 3-4, 15.6%; grade 5, 0%) of patients. Immune-mediated adverse events occurred in 22.0% of patients (grade 3, 5.5%; grade 4-5, 0).A small subset of patients with advanced salivary gland carcinoma treated with pembrolizumab had a response; all had response duration ≥2 years. The safety profile of pembrolizumab was manageable.

Advances in surgical technique and prosthesis design have expanded the non-neoplastic indications for proximal femoral replacement (PFR) to include fracture nonunion, periprosthetic fracture, and severe bone loss in the setting of revision total hip arthroplasty (THA). The purpose of this study is to assess outcomes of PFRs used for nononcologic indications.A single-institution, retrospective, cohort survey study was conducted between August 2015-February 2020 of consecutive patients undergoing PFR for nononcologic indications in revision THA. Patient demographics, surgical variables, complications, and revision procedures were collected. Patient satisfaction and Oxford Hip scores were assessed via a telephone questionnaire. Implant survivorship was estimated using the Kaplan-Meier method.In total, 24 patients (27 PFRs) were available for analysis with an average age of 69.3 ± 12.9 years (range: 37-90). The average number of operations prior to PFR implantation was 3.1 ± 2.1 (range: 0-7). At a mean follow-up of 2.4 years (range: 0.5-5.1), the mean Oxford Hip Score was 31.7 ± 10.2, and mean patient satisfaction was 4.9/5. Six patients (20.7%) experienced a postoperative complication, with dislocation occurring in three patients (10.3%). None of the patients with dual mobility articulations (n = 4) had dislocation. Three-year survivorship was 85.2% (95% CI 71.8%-98.6%) with all-cause reoperations as the endpoint and 100% (95% CI 100.0%-100.0%) with revision for aseptic loosening as the endpoint.The current study demonstrates excellent short-term survivorship, satisfactory patient-reported outcomes, and high patient satisfaction following PFR for nononcologic indications during revision THA utilizing modern techniques. The most common mode of failure was dislocation requiring reoperation with revision to constrained acetabular components.

Previous studies have demonstrated that patients with abnormal spinopelvic motion are at increased risk of dislocation. However, little is known about the effect of hip offset on dislocation risk following total hip arthroplasty (THA) in patients with abnormal spinopelvic motion. The purpose of this study is to investigate the prevalence of under-restored hip offset and spinopelvic abnormalities in a series of THA patients treated for recurrent instability.This is a retrospective review of consecutive patients treated for hip instability following primary THA (THA+I) from 2012 to 2020. Patient demographics, surgical variables, and radiographic parameters were recorded. THA+I patients were compared to an age-matched and gender-matched control THA population without hip instability (THA). Univariate analyses were performed to compare differences between groups.Thirty-three THA+I patients (44 hips) were compared to 44 THA patients (44 hips). THA+I patients had a higher prevalence of spinopelvic pathology (odds ratio [OR] 7.80, 95% confidence interval [CI] 2.59-23.50, P.001). The majority of acetabular components were placed within the Lewinnek safe zone (86.4% THA+I vs 72.7% THA; P = .119). THA+I patients were at greater risk of markedly under-restored hip offset (Δoffset ≤ 3 mm; OR 6.34, 95% CI 2.20-18.30, P = .001) and small (32 mm) femoral head diameter (OR 4.38, 95% CI 1.53-12.53, P = .006) compared to THA patients.Lumbar degenerative disease and under-restoration of hip offset were present in a high proportion of patients with hip instability. Although multiple factors may contribute to THA instability, these data suggest that restoration of offset is essential, particularly in patients with spinopelvic pathology, and may be more important than historically described acetabular targets.Level III.

Surgical residents are increasingly concerned about inequities in patient access and outcomes. This study reviews general surgery residency programs websites for educational and community-focused efforts to recognize and intervene on the root causes of structural inequities.We reviewed the websites of the 332 ACGME-accredited general surgery residency programs for mission statement, curriculum and research details in addition to diversity, equity and inclusion statements. Through deductive coding, we pursued a thematic analysis of visible and intentional steps to incorporate and emphasize surgical equity in surgical training.The majority (76%) of training program websites do not mention healthcare inequity. Of the programs that do, 24 (7% of all residencies reviewed) describe initiatives, including an endowed lectureship in anti-racism and community engagement work.We identified efforts to prioritize surgical equity at general surgery residency programs across a range of resources and settings. This review of public efforts toward equity highlights opportunities for programs to engage with their trainees and communities.

Revision thumb carpometacarpal (CMC) arthroplasty alleviates persistent pain and instability after nonimplant or implant CMC arthroplasty. Metacarpal subsidence onto the scaphoid causing impingement, missed diagnosis such as scaphotrapezoid arthritis, and metacarpophalangeal hyperextension are common causes of failed CMC arthroplasty. Literature shows that revision CMC arthroplasty has satisfactory outcomes. Currently, the mantra of revision is to restore the metacarpal height and treat concomitant pathology, but no single operation is a universal solution. Revision CMC arthroplasty has a relatively high complication rate, lower patient satisfaction than primary CMC arthroplasty, and may result in the need for further operative intervention.

Purpose A substantial amount of waste is generated during surgery, yet few studies have investigated this problem. Therefore, we conducted a multicenter survey to investigate how the variation in the use of disposable supplies contributes to the environmental and financial burdens of health care. Methods We created a questionnaire to identify differences in supply use and practice characteristics among hand surgeons who participated in the Wrist and Radius Injury Surgical Trial. We determined the average cumulative cost of 10 key surgical items based on the responses. Subsequently, we estimated the kilograms of carbon dioxide emitted during the life cycle of supplies, from raw material extraction to production and disposal, using economic input-output life cycle analysis. Results Thirty-five surgeons from 19 institutions responded to the survey (65% response rate). Based on the difference in costs between surgeons who used the fewest and the most supplies, we determined that expenditures and carbon dioxide emissions could decrease by $22.47 and 10.9 kg per procedure, respectively, with leaner use of 10 key items. Furthermore, assuming that surgeon variation in supply use is present in other surgical subspecialties, we estimated that $2.4 billion in savings and an 800.6 thousand metric ton reduction in carbon emissions could be achieved if all US surgeons reduced their supply use by this amount. Conclusions This study revealed considerable variations in the use of disposable supplies among hand surgeons, highlighting the need for evidence-based tools, policies, and education campaigns to reduce hospital waste across health care systems. Clinical relevance Optimal use of disposable supplies is necessary to reduce the cost and environmental burden of hand surgery care.

Extensor carpi ulnaris tendon subluxation can be a challenging diagnosis as a cause of wrist pain. The tendon is stabilized by a tough subsheath. This subsheath is vulnerable to tears in acute wrist movements, especially those combining supination, flexion, and ulnar deviation. The patient presenting acutely may experience swelling, tenderness, and pain. In a chronic setting, the complaint is often an unstable wrist. The diagnosis can be made with a thorough examination, and ultrasonography can be used to evaluate the dynamics of the tendon. Surgical repair with a flap of extensor retinaculum to re-create the tendon's stabilizing subsheath is recommended.

Purpose To determine whether functional vision and visual function improvements after voretigene neparvovec (VN; Luxturna [Spark Therapeutics, Inc]) administration in patients with biallelic RPE65 mutation-associated inherited retinal disease are maintained at 3 to 4 years and to review safety outcomes. Design Open-label, randomized, controlled phase 3 trial. Participants Thirty-one individuals were enrolled and randomized 2:1 to intervention (n = 21) or control (n = 10). One participant from each group withdrew before, or at, randomization. Methods Patients in the original intervention (OI) group received bilateral subretinal VN injections. Delayed intervention (DI) patients served as control participants for 1 year then received VN. Main Outcome Measures Change from injection baseline in bilateral performance on the multiluminance mobility test (MLMT), a measure of ambulatory navigation, and change from injection baseline in full-field light sensitivity threshold white light, visual field (VF), and visual acuity (VA). Results Mean bilateral MLMT change scores at year 4 for OI patients and year 3 for DI patients were 1.7 and 2.4, respectively, with 71% of patients with a year 3 visit able to pass MLMT at the lowest light level. Mean change in full-field light sensitivity threshold white light, averaged over both eyes at year 4 for OI patients and year 3 for DI patients, was −1.90 log10(cd.s/m2) and −2.91 log10(cd.s/m2), respectively. Mean change in Goldmann kinetic VF III4e sum total degrees, averaged across both eyes, was 197.7 at year 4 for OI patients and 157.9 at year 3 for DI patients. Mean change in VA (Holladay scale), averaged across both eyes, was –0.003 logarithm of the minimum angle of resolution (logMAR) at year 4 for OI patients and −0.06 logMAR at year 3 for DI patients. One OI patient experienced retinal detachment at approximately year 4 that impacted VA for the OI group. No product-related serious adverse events (AEs) occurred, nor did any deleterious immune responses. Conclusions Improvements in ambulatory navigation, light sensitivity, and VF were consistent in both intervention groups. Overall, improvements were maintained up to 3 to 4 years, with ongoing observation. The safety profile of VN was consistent with vitrectomy and the subretinal injection procedure and was similar between intervention groups, with no product-related serious AEs reported.

BACKGROUND: Gastrointestinal dysfunction is a frequent and disabling manifestation of autoimmune polyendocrine syndrome type 1 (APS-1), a rare monogenic multi-organ autoimmune disease caused by the loss of central AIRE-controlled immune tolerance. OBJECTIVE: We aimed to understand the role of the gut microbiome in APS-1 symptoms and potentially alleviate common gastrointestinal symptoms by probiotic intervention. METHODS: We characterized the fecal microbiomes of 28 APS-1 patients and searched for associations with gastrointestinal symptoms, circulating anti-cytokine autoantibodies and tryptophan-related metabolites. We additionally administered daily doses of the probiotic Lactobacillus rhamnosus GG for three months. RESULTS: Of 581 metagenomic operational taxonomic units (mOTUs) characterized in total, 14 were significantly associated with APS-1 compared to healthy controls, with six mOTUs depleted and eight enriched in APS-1 patients. Four overabundant mOTUs were significantly associated with severity of constipation. We observed phylogenetically conserved microbial associations with autoantibodies against cytokines. After the three-month intervention with the probiotic L. rhamnosus GG, a subset of gastrointestinal symptoms were alleviated. L. rhamnosus GG abundance was increased post-intervention and corresponded with decreased abundances of Alistipes onderdonkii and Collinsella aerofaciens, two species positively associated with severity of diarrhea in APS-1 patients. CONCLUSION: The APS-1 microbiome correlates with several APS-1 symptoms, some of which are alleviated after a three-month L. rhamnosus GG intervention. Autoantibodies against cytokines appear to shape the gut microbiome by positively correlating with a taxonomically consistent group of bacteria. CLINICAL IMPLICATIONS: Administration of L. rhamnosus GG appears to alleviate certain gastrointestinal symptoms of APS-1.

With the development of newer techniques for symptomatic neuroma treatment, such as regenerative peripheral nerve interface and targeted muscle reinnervation, transposition and coverage techniques often have been referred to as "passive techniques." In spite of its negative connotation, these passive techniques yield positive results in a majority of patients treated. The experienced surgeon has more options than ever before in the prevention and management of problematic neuromas. Critical appraisal of the current literature reveals no single, optimal standard of care. Instead, surgeons have a plethora of useful techniques that can be implemented on a case-by-case basis to optimize outcomes.

Repetitive stress on the lumbosacral spine during sporting activity places the athletic patient at risk of developing symptomatic pars defect. Clinical history, physical examination, and diagnostic imaging are important to distinguish spondylolysis from other causes of lower back pain. Early pars stress reaction can be identified with advanced imaging, before the development of cortical fracture or vertebral slip progression to spondylolisthesis. Conservative management is first-line for low-grade injury with surgical intervention indicated for refractory symptoms, severe spondylolisthesis, or considerable neurologic deficit. Prompt diagnosis and management of spondylolysis leads to good outcomes and return to competition for most athletes.

Surgical registries have provided reliable, generalizable, and applicable clinical data that have shaped many fields. Broad collection of defined data can answer clinical questions with greater numbers of patients and more ability to generalize to routine clinical care than randomized trials. National hand surgical registries exist outside the United States. Before the pursuit of a registry, the focus of such an effort must be defined to ensure that registry goals are feasible. This article presents the consensus process conducted by the American Society for Surgery of the Hand's Registry Task Force exploring potential diagnoses for a hand registry.

Athletic injuries of the hip often require radiographs and advanced imaging for diagnosis. Plain radiographs evaluate for osseous injury, provide a structural context behind an athlete's symptoms and examination, and offer a backdrop for interpretation of advanced imaging. An understanding of normal anatomy, imaging findings, and radiographic measurements allows for recognition of pathoanatomy and ability to diagnose accurately. Advanced imaging modalities, including magnetic resonance imaging, computed tomography, and ultrasonography, each play a role in evaluation of the athlete's hip. Although MRI and CT provide high-resolution imaging of the hip, ultrasonography offers the unique ability to perform dynamic imaging and guided injections.

Purpose To evaluate factors that predict the use of electrodiagnostic testing (EDS) for patients undergoing carpal tunnel release (CTR). Methods In this cohort study, we analyzed 553 patients who underwent primary CTR from 8 practices between July 1, 2019 and December 1, 2019 by 32 surgeons in the Michigan Collaborative Hand Initiative for Quality in Surgery (M-CHIQS). The M-CHIQS is a collaborative initiative aimed at improving quality in hand surgery. Demographic and clinical characteristics were collected, including the 6-item carpal tunnel symptoms scale (CTS-6) scores and EDS timing. Multilevel logistic regression was used to assess practice and surgeon variation in EDS use related to clinical diagnostic criteria. Results Of the 553 patients who underwent CTR during the study period, 461 (83.3%) received preoperative EDS. After controlling for patient clinical and demographic characteristics, CTS-6 scores were not associated with receiving any preoperative EDS (lower probability of CTS: odds ratio [OR], 0.94; 95% confidence interval [95% CI], 0.59–1.51), preconsultation EDS (low probability of CTS: OR, 1.00; 95% CI, 0.73–1.38), or postconsultation EDS (low probability of CTS, OR, 1.10; 95% CI, 0.77–1.60). For use of any EDS, 9.3% of the variation in testing was explained at the practice level and 31.1% of the variation in testing was explained at the surgeon level. Conclusions Variation in EDS use is explained primarily at the practice and surgeon levels and is not related to patient clinical criteria. We recommend that providers and practices assess their use of preoperative EDS and limit its use to patients with an unclear clinical CTS diagnosis, as stated in current clinical practice guidelines. Likewise, providers should be encouraged to use the CTS-6 before prescribing EDS. Clinical relevance Limiting the use of EDS to patients with an unclear clinical diagnosis of CTS will reduce costs and improve patient care by eliminating the discomfort and time associated with this test.

Despite the use of various factors to measure hospital quality, most measures have not resulted in long-term improvements in patient outcomes. This study's purpose is to determine the effect of a previously unassessed measure of quality of care-a hospital's preventable hospitalization rate-on 30-day mortality at both the hospital and individual levels after three major cardiovascular surgery procedures. This is a population-based study using Taiwan's National Health Insurance database. We retrieved data from 2001 to 2014 for patients who had undergone abdominal aortic aneurysm (AAA) repair, coronary artery bypass graft, or aortic valve replacement (AVR). Preventable hospitalizations are hospitalizations for 11 chronic conditions that are considered preventable with effective primary care. The outcome was 30-day surgical mortality. Our dataset contained 65,863 patients who had undergone surgery for one of the three cardiovascular procedures. Preventable hospitalization rate was significantly associated with higher hospital mortality rates for all procedures. At the patient level, the adjusted odds of mortality after AAA repair were increased 55% (P0.01) for every 2% increase in the preventable hospitalization rate. For coronary artery bypass graft, preventable hospitalization was not a significant predictor of mortality, but rather patient factors and surgeon factors were significant. For AVR, the adjusted odds of mortality were increased 7% (P0.01) for every 1% increase in preventable hospitalization rate. High preventable hospitalization rate may serve as a hospital quality measure that could signal increased odds of mortality for selected cardiovascular procedures, especially for higher risk-lower volume procedures such as AAA repair and AVR.

Resume Objectif Notre etude avait pour objectif de rechercher le risque d’hospitalisation evitable chez les patients atteints de polyarthrite rhumatoide (PR). Methodes Nous avons identifie 11 852 patients PR et 59 260 temoins apparies sur l’âge, le sexe et l’annee index et issus de la base de donnees du systeme national d’assurance maladie de Taiwan. La date index correspondait a la date du diagnostic de PR pour les cas et a ete assignee a leurs temoins apparies. Les odds ratios (OR) des hospitalisations evitables entre les patients PR et les temoins ont ete estimes a l’aide d’un modele mixte ajuste sur l’âge, le sexe, les caracteristiques des patients, l’indice de comorbidite d’Elixhauser, le recours aux soins et l’offre de soins regionale. Resultats L’incidence annuelle globale des hospitalisations evitables chez les patients PR et les temoins s’elevait a 38,7 vs. 20,9 evenements pour 1000 personnes–annees (OR ajuste, 1,61 ; intervalle de confiance a 95 % [IC], 1,51–1,71). L’OR ajuste des hospitalisations evitables chez les patients PR comparativement aux temoins apparies etait de 1,17 (1,00–1,37) un an avant le diagnostic de PR tout en conservant des niveaux eleves apres le diagnostic de PR. Les ORs ajustes (IC 95 %) pour les categories specifiques d’hospitalisations evitables etaient de 1,93 (1,58–2,36) pour la maladie pulmonaire chronique obstructive (BPCO), 1,64 (1,21–2,21) pour l’asthme, 1,95 (1,78–2,13) pour la pneumonie bacterienne et 1,59 (1,44–1,75) pour les infections urinaires. Selon l’analyse de la tendance de chaque categorie d’hospitalisation evitable avant et apres le diagnostic, les hospitalisations pour pneumonie bacterienne et infection urinaire affichaient un OR significativement plus eleve chez les patients PR un an avant le diagnostic et cinq ans apres le diagnostic (OR ajuste variant respectivement de 2,75 a 4,48 et de 1,83 a 3,07, toutes les valeurs de p Conclusion La PR est associee de maniere independante a un taux plus eleve d’hospitalisations evitables, en particulier pour les maladies pulmonaires chroniques et les infections.

Familial adenomatous polyposis (FAP) is characterized by high risks of colonic and extracolonic tumors. Recent studies have suggested a rising risk for gastric cancer (GC). We sought to define the spectrum of premalignant gastric polyps in FAP, focusing on high-grade dysplasia (HGD).The gastric phenotypes of 118 patients diagnosed with FAP or attenuated FAP in our Hereditary Gastrointestinal Cancer Registry were retrospectively reviewed. To analyze the clinical features associated with the diagnosis of HGD, we established an age- and sex-matched control group of FAP patients from our cohort without gastric HGD in a 4:1 ratio.The spectrum and frequency of gastric polyps in individuals with FAP included fundic gland polyps (67.9%), hyperplastic polyps/foveolar hyperplasia (19.6%), tubular adenomas (15.2%), foveolar adenomas (10.7%), and pyloric gland adenomas (6.3%). Ten patients (8.9%) exhibited gastric HGD at a mean age of 55 ± 13 years, and HGD was seen in all polyp types. When compared with control subjects, HGD was associated with a high diversity of gastric polyp histology, prior low-grade dysplasia, severe gastric polyposis, and prior Whipple surgery (P = 2.0E-5, .003, .024, and .04, respectively). Two patients (1.7%) with HGD were diagnosed with GC. However, the remaining 8 patients with HGD have been under surveillance for an average of 5.8 ± 4.5 years without progression to GC.Gastric HGD in FAP may be more common than previously appreciated. The natural history of HGD is variable, and most patients with HGD do not appear to progress to GC.

Distal radius fractures with severe displacement or concomitant triangular fibrocartilage complex tears may be accompanied by distal radioulnar joint instability. Clinicians should examine the distal radioulnar joint closely when managing wrist fractures and treat coexisting instability appropriately. Chronic instability from distal radius malunion may require osteotomy or radioulnar ligament reconstruction. With proper management, most patients recover forearm stability and rotational motion after distal radius fracture.

Upper extremity infections are common. Most infections can be effectively treated with minor surgical procedures and/or oral antibiotics; however, inappropriate or delayed care can result in significant, long-term morbidity. The basic principles of treating hand infections were described more than a century ago and most remain relevant today. Immunosuppressant medications, chronic health conditions such as diabetes and human immunodeficiency virus, and public health problems like intravenous drug use, have changed the landscape of hand infections and provide new challenges in treatment.

Purpose Accurate financial disclosure is essential to prevent bias in scientific reporting. We aimed (1) to document the extent of industry financial payments to hand surgery literature authors and (2) to uncover discrepancies in author self-declared conflict of interest (COI). Methods We screened all scientific and review articles published in 2017 from the American editions of 4 peer-reviewed journals (Journal of Hand Surgery [JHS], Journal of Bone and Joint Surgery [JBJS], Plastic and Reconstructive Surgery [PRS], and Journal of the American Academy of Orthopaedic Surgeons [JAAOS]) to identify authors of hand, wrist, elbow, and peripheral nerve topics. We compared self-reported disclosures with industry-reported payments on the Centers for Medicare and Medicaid Services’ Open Payments Database (OPD) for 3 years prior to publication or per journal policy. We individually examined each for relevance of the corporate payer to the article’s subject matter. Results We found 630 eligible authors from 395 articles. The total amount of industry-reported payments over 3 years prior to publication was $24,396,607.80. The median total payments per author per year was $118.40, with interquartile range from $0 to $1,364; 68% of authors received some industry payment; the most common being food and beverage (66% of authors). Senior authors received significantly more industry payments (median, $2,985.67/y) than first and middle authors ($70.27 and $113.17, respectively). Of all authors examined, 58% had undisclosed payments, but only 14% were relevant to the article subject matter. Authors in JAAOS & JBJS, senior authors, and those receiving more than $500,000 from industry were less likely to accurately report all payments. Conclusions Industry payments to hand surgery authors were lower than those reported to other orthopedic specialties and tended to be concentrated in a few authors receiving large amounts. Relevant COI disclosure inaccuracies are infrequent within hand surgery literature. Uniform policies of complete disclosure across journals may remove author judgment regarding payment relevance to published material and help eliminate remaining COI errors. Authors may reference the OPD prior to submitting disclosures to prevent potential discrepancies and identify errors within the database. Clinical relevance Relationships with industry offer opportunities for innovation, education, and research, but overlooking COI self-reporting may erode confidence in the academic integrity of the hand surgery literature.

Hand therapy is a time-sensitive and essential postoperative service for patients undergoing reparative or corrective procedures in the hand and plays an important role in achieving best functional outcomes. In the United States, therapy is an independent service from a payer's standpoint. Access is affected by global and distinct factors in health care. This article presents views on certain aspects of health care that aide in and those that impede access to hand therapy for patients in the United States, and concludes with a brief glimpse into some ongoing efforts to improve access for patients.

Health services research using secondary data is a powerful tool for guiding quality/performance measure development, payment reform, and health policy. Patient preferences, physical examination findings, use of postoperative care, and other factors specific to hand surgery research are critical pieces of information required to study quality of care and improve patient outcomes. These data often are missing from data sets, causing limitations and challenges when performing secondary data analyses in hand surgery. As the role of secondary data in surgical research expands, hand surgeons must apply novel strategies and become involved in collaborative initiatives to overcome the limitations of existing resources.

Considerable variation exists in the practice of hand surgery that may lead to wasteful spending and less than optimal quality of care. Hand surgeons can benefit from a centralized system that tracks process and outcome measures, delivers national benchmarking, and encourages the sharing of knowledge. A national registry can fulfill these needs for hand surgeons and incorporate quality improvement into their daily routine. Leaders in hand surgery should convene to appraise the organization of a national registry for their field and reach consensus on how the registry can be designed and funded.

Each step of the evidence-based practice process is critical and requires clear understanding for accurate application. To practice evidence-based care, providers must acquire a specific skillset that facilitates translation of a patient problem into an answerable research question. Additional requirements are understanding of electronic databases, critical appraisal of the available evidence, and integration of the findings to generate a specific, individualized treatment plan. Although this process is demanding, evidence-based practice is essential in the delivery of optimal patient care.

Collaboration with organizations beyond the clinical setting is necessary to identify safety hazards that contribute to the high incidence and severity of hand conditions. Hand surgeons are acutely aware of obstacles patients face while navigating the health care system. Advocacy efforts encourage the development of equitable insurance policies and improve health resource allocation so that hand surgeons can treat a larger patient population. Participation in quality initiatives supports the development of evidence-based clinical guidelines. Further evidence must be generated to ensure that surgeons remain proficient in the latest techniques and uphold high standards of care as hand surgery procedures evolve.

We investigated whether genetic susceptibility to tuberculosis (TB) influences lung adenocarcinoma development among never-smokers using TB genome-wide association study (GWAS) results within the Female Lung Cancer Consortium in Asia. Pathway analysis with the adaptive rank truncated product method was used to assess the association between a TB-related gene-set and lung adenocarcinoma using GWAS data from 5512 lung adenocarcinoma cases and 6277 controls. The gene-set consisted of 31 genes containing known/suggestive associations with genetic variants from previous TB-GWAS. Subsequently, we followed-up with Mendelian Randomization to evaluate the association between TB and lung adenocarcinoma using three genome-wide significant variants from previous TB-GWAS in East Asians. The TB-related gene-set was associated with lung adenocarcinoma (p = 0.016). Additionally, the Mendelian Randomization showed an association between TB and lung adenocarcinoma (OR = 1.31, 95% CI: 1.03, 1.66, p = 0.027). Our findings support TB as a causal risk factor for lung cancer development among never-smoking Asian women.

Hand surgery leadership in the United States must identify and define what quality care means for its patients. To achieve this, the surgical team needs a standardized framework to track and improve quality. This is necessary not only in our value-based health care system but also in light of considerable provider variation in the management of common hand conditions and the ongoing need for evidence-based guidelines to inform decision-making. Building a national registry for the field of hand surgery could be the solution and warrants serious consideration. A registry designed by hand surgery experts can collect data on process and outcome measures that are meaningful and specific to patients with hand conditions. These data inform the surgical team regarding where to focus their efforts for improvement. Existing methods of quality measurement are not compatible with hand surgery, a field with an ambulatory setting and rare incidence of mortality. Patient-reported outcomes, such as health-related quality of life, represent a more useful measure of quality for hand surgery and are just one example of the type of data that could be tracked using a national registry. An investment in a large-scale registry could seamlessly integrate patient preferences, values, and expectations into clinical practice so that desired outcomes can be delivered consistently across the nation.

The prevention and treatment of hand injuries in low- to middle-income countries needs to be a priority. Surgical outreach trips are a primary avenue for patients to receive interventions. Challenges include language and cultural barriers, poor infrastructure, and limitations in a patient's ability to follow-up. Strategies to maximize patient functional outcomes include cultural competence, patient education resources, overcoming communication barriers, and using task-shifting strategies. Local therapists' knowledge and clinical skills can be enhanced. With improvements in data collection, therapists may contribute to gaining knowledge of outcomes in low- to middle-income countries.

Hand trauma surgical treatment and perioperative therapy are often lacking in low- and middle-income countries resulting in high rates of patient morbidity following injury. Providing education through a multifaceted approach including in-person teaching, written resources, videos, and Internet and social media platforms and facilitating skill acquisition through simulation permits local providers to gain expertise in hand trauma care and thus benefits patients. This article outlines challenges faced by low- and middle-income countries in caring for hand trauma patients and possible implementable solutions.

As the population increases in the world's poorest countries, the need for surgical interventions will increase. Short-term surgical missions can play an important role in increasing access to solve this disparity by providing much-needed surgical services to vulnerable populations in low-income and middle-income countries. As short-term surgical missions increase, it is important that basic ethical principles are a foundation in service delivery. By following ethical principles outlined in this article, abiding by common moral language, and establishing long-term relationships, a significant contribution can be made to global surgery to increase access and deliver high-quality surgery.

Burns are devastating injuries that cause significant morbidity, emotional distress, and decreased quality of life. Advances in care have improved survival and functional outcomes; however, burns remain a major public health problem in developing countries. More than 95% of burns occur in low- and middle-income countries, where access to basic health care is limited. The upper extremity is involved in the majority of severe burn injuries. The purpose of this article is to review upper extremity burn epidemiology, risk factors, prevention strategies, and treatment options in resource-limited settings.

Multiple anthropogenic activities are driving the salinization of freshwater environments threatening water resources worldwide. Accordingly, this research will first examine the spatial and temporal variability of major ions (i.e. Ca2+, Mg2+, Na+, K+, SO42−, CO32−, and HCO3−) upstream and downstream of the northernmost major city in North America (Edmonton, Canada). Second, this research will estimate the relative contributions of the major sources of chloride (Cl), the main constituent of road deicers, to the sub-basin around Edmonton. Monthly water quality data was for three sites on the North Saskatchewan River (NSR): Rocky Mountain House (RMH - downstream of the Rocky Mountain headwaters), Devon Bridge (upstream of Edmonton) and Pakan Bridge (downstream of Edmonton). Change ratios investigate the downstream alterations of major ions at Pakan and Devon, relative to RMH. Seasonal Kendall tests examine temporal trends (1987–2017). A mass-balance approach then quantifies the major sources of Cl in the sub-basin of the NSR between Devon and Pakan. Progressing from the Rocky Mountain headwaters (at RMH) to downstream of Edmonton (at Pakan), Cl− increased by >5.5 times, Na+ by 4.8 times and K by 2.7 times. No significant temporal trends for Cl−, Na+ and K+ were evident at Devon (upstream of Edmonton), whereas all three significantly increased at Pakan (downstream of Edmonton). Deicers (54%), agriculture (20%), along with waste water treatment plant and industrial effluent (15%) were the largest Cl sources in the NSR Devon-Pakan sub-basin. In total, 77 Gg yr−1 of Cl (or 6 t km2 yr−1) is added to the Devon-Pakan sub-basin, of which, 43 Gg yr−1 is retained. Understanding and managing the major drivers of freshwater salinization will be of increasing importance in the 21st century owing to the potential salinization of freshwater resources in the context of a changing climate.