Dr. David Lhowe, orthopaedic trauma surgeon at Massachusetts General Hospital, spent time in a makeshift field hospital next to what was the World Trade Center after the 9/11 attacks and a month on a US Navy hospital ship helping survivors of the Indonesia earthquake—the deadliest natural disaster in recorded history. Lhowe calls these opportunities to help “an unbelievable gift” in It Takes a Team—The 2013 Boston Marathon: Preparing for and Recovering From a Mass-Casualty Event, a special report co-published by JBJS and JOSPT.
It Takes a Team describes how Dr. Lhowe performed surgery on Kaitlynn Cates after she sustained deep-tissue shrapnel wounds in her right calf from the Boston Marathon bombings. Cates appreciated his clear and calm explanations of the surgical plan and what would happen after. “In emergencies, it’s often hard for patients to concentrate, so I try to simplify to the best of my ability, lay out the main points of consideration or concern, and continue the conversation later,” he said.
Cates still occasionally visits Lhowe, even though she’s been discharged as a surgical patient. “I find talking to him very comforting,” Cates said. In addition to helping her navigate clinical intricacies of her ongoing care, Lhowe simply lends a sympathetic ear. “If I have the time to talk and if talking helps her, that’s great,” he said.
It Takes a Team-The 2013 Boston Marathon: Preparing for and Recovering From a Mass-Casualty Event is divided into three parts:
- Part 1: Readiness—Fortune Favors Prepared Teams
- Part 2: Response and Recovery—April 15 Through December 31
- Part 3: The Road Ahead—A Long Haul for Each and All
How to prevent pulmonary function deterioration has been a focus in the management of boys with Duchenne muscular dystrophy (DMD) for many years. Since the 1980s it has been thought that an increasing scoliosis is associated with declining pulmonary function at a rate even greater than that from the effects of muscle weakness. As a result, it is common for surgery to be recommended for patients with DMD once a scoliosis of greater than 20 degrees is noted, a much lower threshold than is used for surgical treatment of idiopathic scoliosis. This practice assumes that surgical correction reduces the worsening of pulmonary function, but solid data to support that view has been absent.
The article “Functional Outcomes in Duchenne Muscular Dystrophy Scoliosis” in the March 5, 2014 JBJS confirms that surgical treatment of scoliosis in DMD does lead to better vital capacity, compared with no surgical treatment. However, before deciding that all DMD patients will need spine surgery to slow down pulmonary function worsening, surgeons should keep in mind the current efficacy of early treatment with corticosteroids to prevent scoliosis in this patient group. Not only does corticosteroid treatment prevent scoliosis development in the majority of kids, but the deterioration in pulmonary function is also slowed compared to those without this treatment.
With the information on pulmonary function provided in this article, we now have concrete data for use in discussions with parents on whether to select early treatment with corticosteroids to prevent scoliosis or to wait for surgical correction later. Surgery has risks associated with cardiac and pulmonary compromise inherent in DMD, and corticosteroids carry the risk of stunted growth and the development of cataracts in many patients. This article contributes useful hard data to enhance the process of shared decision making for the spinal care of children with DMD.
A home-based exercise program modestly improved physical function in older adults who completed a standard rehabilitation program after a hip fracture, according to a recent JAMA study.
Half of nearly 200 older adults with limited function after finishing rehab were randomized to home exercises; the other half received in-home and phone-based nutrition education. The exercise group learned functional tasks (such as standing from a chair and climbing a step) during three hour-long home visits by a physical therapist, and then performed the tasks on their own three times weekly for six months. After six months, the exercise group had better scores of physical function — as measured by the Short Physical Performance Battery and Activity Measure for Post-Acute Care — than the control group.
While the clinical importance of these findings remains to be established, the results suggest that an extended period of structured at-home rehabilitation could help older patients sidestep some of the long-term functional limitations that often persist following a hip fracture.
It’s a known fact that zebra fish have innate abilities to regenerate lost appendages and organs, but will researchers be able to crack the code that would make the same thing possible for humans? A recent paper published in Cell Reports shows how the two molecular pathways—the Wnt signaling pathway and the bone morphogenetic protein (BMP) pathway– work together in zebra fish to regenerate fins when they are amputated. University of Oregon (UO) researchers believe that understanding these signaling mechanisms in zebra fish could support the design of regenerative therapies that direct human cells to behave similarly.
According to a UO press release, “The researchers found that cell-to-cell signaling mediated by the Wnt pathway helps existing mature bone cells become progenitor cells after fin amputation.” Then the BMP pathway directs the newly formed cells to develop into functional bone cells. Humans have these same pathways, and defects in them are linked to human bone diseases. Lead author Scott Stewart, PhD, said, “As we discover the cellular and molecular roles of the signals in zebra fish and pinpoint the missing network connections in mammals, maybe we could coax human bones to repair themselves equally as well.”
Dennis Sorensen considers himself fortunate to get a chance that most amputees won’t get: to regain some natural sensation in his left hand. About 10 years ago, his left hand was amputated after a fireworks accident. He recently traveled to Rome to try an experimental prosthetic hand that added sensors to each finger. Then surgeons inserted tiny electrodes into Sorensen’s arm that connected the finger sensors to sensory nerves in his upper arm. Almost immediately, Sorensen was able to feel shapes, sizes, and textures of objects, and he was able to control the strength of his grip. Sorensen has spent almost a year testing the device, and the results of the experiment were reported in a recent issue of Science Translational Medicine.
According to a statistical brief from the Agency for Healthcare Research and Quality, below are the top 10 costliest OR procedures performed in US hospitals during 2011. Aggregate annual costs are shown, followed by average per-stay costs in parentheses. Note that four of the 10 are orthopaedic procedures, with cardiac interventions coming in second, with three of the top 10.
1. Spinal fusion — $12.8 billion ($27,600 per hospital stay)
2. Knee replacement — $11.3 billion ($15,900 per hospital stay)
3. Percutaneous coronary angioplasty — $9.7 billion ($18,800 per hospital stay)
4. Hip replacement — $8 billion ($17,200 per hospital stay)
5. Caesarean section — $7.5 billion ($5,900 per hospital stay)
6. Colorectal resection — $6.7 billion ($23,400 per hospital stay)
7. Coronary artery bypass graft — $6.4 billion ($38,700 per hospital stay)
8. Heart valve procedures — $6.1 billion ($53,400 per hospital stay)
9. Cholecystectomy and common duct exploration — $5 billion ($12,600 per hospital stay)
10. Treatment, fracture or dislocation of hip and femur — $4.3 billion ($16,800 per hospital stay)
A workgroup has submitted draft recommendations for Stage 3 Meaningful Use incentives. Chaired by Paul Tang, MD, the workgroup has put forth various policy ideas over the past 2 years. One proposal would have physicians and hospitals use clinical decision support interventions based on four of six high-priority objectives: preventive care, chronic disease management, appropriateness of lab/rad orders, medication-related decision support, medication and allergy lists, and drug-drug and drug-allergy checks. The workgroup has also proposed new certification standards for electronic health records (EHR) that would make it easier for patients to modify their records online.
Events like the 2013 Boston Marathon bombing can have a tremendous emotional impact on any care provider—physicians, nurses, imaging techs, registration and administrative personnel, transporters, and housekeeping staff. “The solution is not to tell people to ‘suck it up,’” insisted Ron Walls, MD, chair of the Department of Emergency Medicine at Brigham and Women’s Hospital.
Many of the stories in It Takes a Team—The 2013 Boston Marathon, a new Special Report jointly published by JBJS and JOSPT, emphasize the importance of caring for the caregivers–making sure the basic physical and emotional needs of clinicians are met so they can do their jobs of caring for others.
It Takes a Team provides a behind-the-scenes look at how the level 1 trauma centers involved that day (Tufts Medical Center, Beth Israel Deaconess Medical Center, Brigham and Women’s, Boston Medical Center, and Mass General) ensured that their staffs had the emotional backing, resources, and systems in place so they could focus on their seriously injured patients.
Not a single bombing victim who reached a hospital alive on April 15, 2013 died, a stunning result of years of preparation and teamwork. But the lives that were given back to the survivors had changed forever—along with the lives of the clinicians who cared for them. Everyone directly exposed to the Marathon trauma will have emotional ups and downs, and those who seemed unaffected early on may develop problems later. So caring for the caregivers will be an ongoing obligation.
It Takes a Team—The 2013 Boston Marathon: Preparing for and Recovering From a Mass-Casualty Event is divided into three parts:
Part 1: Readiness—Fortune Favors Prepared Teams
Part 2: Response and Recovery—April 15 Through December 31
Part 3: The Road Ahead—A Long Haul for Each and All
In a study in the February Journal of Hand Surgery, nearly a third of all people who sustained a cat bite to the hand ended up hospitalized for treatment of a serious infection. Among those hospitalized, the average length of stay was 3.2 days, mostly for surgical procedures, including irrigation and debridement, and administration of appropriate antibiotics.
One major risk factor for hospitalization was a bite located over a joint/tendon sheath, rather than one located over soft tissue. Study co-author Brian Carlsen of the Mayo Clinic explained further in an interview with USA Today: “When the cat bites the hand, the joints and tendons are protected with fluid and there is no circulation, so bacteria can grow like crazy.” The most common pathogen isolated in cultures was Pasturella multocida, which the study authors described as “one of the most aggressive pathogens isolated from the saliva of 70% to 90% of cats.”
The authors conclude that “there should be a low threshold for aggressive treatment” in patients who present with a cat bite to the hand along with lymphangitis, erythema, and swelling. Or, as Dr. Carlsen told USA Today (with tongue presumably in cheek): “Rule of thumb–go see a doctor if a cat bites your hand.”
The article “Adult human mesenchymal stem cells delivered via intra-articular injection to the knee following partial medial menisectomy” is an interesting report of a randomized, double-blind, controlled study carried out over a 2-year period following subtotal medial menisectomy.
While the positive impact of mesenchymal stem cells (MSCs) on both the meniscus and articular cartilage has been demonstrated in animal models, this study looks at the potentially beneficial effects in humans after partial menisectomy. MSC injection in this setting resulted in no apparent complication secondary to these injections. Pain in patients with osteoarthritis was also improved over 2 years compared to those patients treated only with hyaluronate injection. Most intriguing, though, was that in 24% of patients with lower dose MSC and in 6% with higher dose MSC, there was an increase in meniscal volume on MRI by > 15%. None in the control group showed any volume change.
With the large number of meniscal injuries treated surgically in all age groups, MSC injection following partial menisectomy may prove to be a safe method to decrease osteoarthritic pain and potentially increase the volume of the remaining meniscus.