Establishing Consensus on Essential Resources for Musculoskeletal Trauma Care Worldwide: A Modified Delphi Study.

BACKGROUND: Despite evidence that formalized trauma systems enhance patient functional outcomes and decrease mortality rates, there remains a lack of such systems globally. Critical to trauma systems are the equipment, materials, and supplies needed to support care, which vary in availability regionally. The purpose of the present study was to identify essential resources for musculoskeletal trauma care across diverse resource settings worldwide. METHODS: The modified Delphi method was utilized, with 3 rounds of electronic surveys. Respondents consisted of 1 surgeon with expertise in musculoskeletal trauma per country. Participants were identified with use of the AO Trauma, AO Alliance, Orthopaedic Trauma Association, and European Society for Trauma and Emergency Surgery networks. Respondents rated resources on a Likert scale from 1 (most important) to 9 (least important). The "most essential" resources were classified as those rated ≤2 by ≥75% of the sampled group. RESULTS: One hundred and three of 111 invited surgeons completed the first survey and were included throughout the subsequent rounds (representing a 93% response rate). Most participants were fellowship-trained (78%) trauma and orthopaedic surgeons (90%) practicing in an academic setting (62%), and 46% had >20 years of experience. Respondents represented low-income and lower-middle-income countries (LMICs; 35%), upper-middle income countries (UMICs; 30%), and high-income countries (HICs; 35%). The initial survey identified 308 unique resources for pre-hospital, in-hospital, and post-hospital phases of care, of which 71 resources achieved consensus as the most essential. There was a significant difference (p < 0.0167) in ratings between income groups for 16 resources, all of which were related to general trauma care rather than musculoskeletal injury management. CONCLUSIONS: There was agreement on a core list of essential musculoskeletal trauma care resources by respondents from LMICs, UMICs, and HICs. All significant differences in resource ratings were related to general trauma management. This study represents a first step toward establishing international consensus and underscores the need to prioritize resources that are locally available. The information can be used to develop effective guidelines and policies, create best-practice treatment standards, and advocate for necessary resources worldwide. CLINICAL RELEVANCE: This study utilized the Delphi method representing expert opinion; however, this work did not examine patient management and therefore does not have a clinical Level of Evidence.

How resources affect management of periprosthetic fractures of the distal femur: perspectives from Israel, South Sudan, and South Africa.

Periprosthetic fractures of the distal femur have significant morbidity in both total hip and total knee arthroplasty (THA and TKA, respectively). The incidence of these fractures is growing, with the predominant mechanism of injury being a fall from a standing height and therefore considered fragility fractures. In many countries, improved public funding and a flourishing private health care sector, when coupled with increased life expectancy, translates to more older patients receiving both TKA and THA and therefore an increased prevalence of periprosthetic fractures and their associated complications. These fractures may occur below a long stem THA, above a TKA, or between the two (so-called "interprosthetic fracture"). We will outline fracture classification, risk factors, diagnosis, and treatment options, highlighting perspectives on treating these fractures in Israel, South Africa, and South Sudan. These countries represent differing access to resources, varied comorbidity factors, and differing health care systems. The points of difference and the points of similarity will be considered.

Fragility fracture management and FLS models in South Africa and Israel.

Osteoporosis is a common disease of the elderly. Many patients at high risk are neither identified nor treated. A Fracture Liaison Service is a coordinated model of care for secondary fracture prevention. Several national quality indicators have been published in each country to improve surgical treatment and osteoporosis medical treatment. Fracture Liaison Services in both countries have been created by local clinicians with different models depending on the medical geographic locations of patients and the local setup. The objective of this review is to describe the national guidelines and the current clinical treatment models for fragility fractures in South Africa and Israel. Successes and barriers to successful implementation have been identified and are summarized.

Academic Acceleration in Gifted Youth and Fruitless Concerns Regarding Psychological Well-Being: A 35-Year Longitudinal Study.

Academic acceleration of intellectually precocious youth is believed to harm overall psychological well-being even though short-term studies do not support this belief. Here we examine the long-term effects. Study 1 involves three cohorts identified before age 13, then longitudinally tracked for over 35 years: Cohort 1 gifted (top 1% in ability, identified 1972-1974, N = 1,020), Cohort 2 highly gifted (top 0.5% in ability, identified 1976-1979, N = 396), and Cohort 3 profoundly gifted (top 0.01% in ability, identified 1980-1983, N = 220). Two forms of educational acceleration were examined: 1. Age at high school graduation, and 2. Quantity of advanced learning opportunities pursued prior to high school graduation. Participants were evaluated at age 50 on several well-known indicators of psychological well-being. Amount of acceleration did not covary with psychological well-being. Study 2, a constructive replication of Study 1, utilized a different high-potential sample-elite science, technology, engineering, and mathematics graduate students (N = 478) identified in 1992. Their educational histories were assessed at age 25 and they were followed up at age 50 using the same psychological assessments. Again, the amount of educational acceleration did not covary with psychological well-being. Further, the psychological well-being of participants in both studies was above the average of national probability samples. Concerns about long-term social/emotional effects of acceleration for high-potential students appear to be unwarranted, as has been demonstrated for short-term effects.

Hip fracture care and national systems in Israel and South Africa.

Despite the same latitude on earth, Israel and South Africa have a wide variety of healthcare systems and approaches. Israel is a developed country with life expectancy within the first decile of the modern world. South Africa is a developing country where available resources and health care varies greatly across the country. Israeli policy makers have realized in 1999 the importance of early surgery for hip fractures as the single most important factor contributing to decreased mortality. After an introduction of a newer reimbursement system in 2004, and public advertising of early hip fracture treatment as a quality tag for hospitals, in more than 85% of the cases patients are operated on early (within 8 hours) with a significant decrease in mortality. However, other issues such as patient preparation, rehabilitation, and prevention are still at their beginning. South Africa deals with significant challenges with high energy hip fractures in a younger population, although osteoporosis is on the rise in certain parts of the country. Due to limited resources and distances, time to surgery differs among hospital systems in the country. In public hospitals, a delay up to a week may be common, whereas in private hospitals most patients are operated early within 48 to 72 hours. Due to decreased life expectancy, arthroplasty is more aggressively used in displaced femoral neck fractures. Rehabilitation is mostly done within the families. Prevention and orthogeriatric teamwork are not being commonly practiced. Generally speaking, more attention to hip fractures is needed from healthcare funders.

Psychological Constellations Assessed at Age 13 Predict Distinct Forms of Eminence 35 Years Later.

This investigation examined whether math/scientific and verbal/humanistic ability and preference constellations, developed on intellectually talented 13-year-olds to predict their educational outcomes at age 23, continue to maintain their longitudinal potency by distinguishing distinct forms of eminence 35 years later. Eminent individuals were defined as those who, by age 50, had accomplished something rare: creative and highly impactful careers (e.g., full professors at research-intensive universities, Fortune 500 executives, distinguished judges and lawyers, leaders in biomedicine, award-winning journalists and writers). Study 1 consisted of 677 intellectually precocious youths, assessed at age 13, whose leadership and creative accomplishments were assessed 35 years later. Study 2 constituted a constructive replication-an analysis of 605 top science, technology, engineering, and math (STEM) graduate students, assessed on the same predictor constructs early in graduate school and assessed again 25 years later. In both samples, the same ability and preference parameter values, which defined math/scientific versus verbal/humanistic constellations, discriminated participants who ultimately achieved distinct forms of eminence from their peers pursuing other life endeavors.

Distal interlocking screw placement in the femur: free-hand versus electromagnetic assisted technique (sureshot).

OBJECTIVES: To compare the free-hand (FH) technique of placing interlocking screws to a commercially available electromagnetic (EM) targeting system in terms of operating time, radiation dose, and accuracy of screw placement. METHODS: Between September 2011 and July 2012, we prospectively randomized 100 consecutive femur shaft fractures in 99 patients requiring intramedullary nails to either FH using fluoroscopy (n = 43) or EM targeting (n = 38; Sureshot). SETTING: Single Level 1 University Hospital Trauma Center. MAIN OUTCOME MEASUREMENTS: The 2 groups were assessed for distal locking with respect to time, radiation, and accuracy. RESULTS: Eight-one fractures had data accurately recorded (38 EM/43 FH). The average total operative time was 50 minutes (range, 25-88 minutes; SD, 13.9 minutes) for the FH group and 57 minutes (range, 40-103 minutes; SD, 16.12 minutes) for the EM group. The average time for distal locking was 10 minutes (range, 4-16 minutes; SD, 3.56 minutes) with FH and 11 minutes (range, 6-28 minutes; SD, 10.24 minutes) with EM. Average radiation dose for distal locking was significantly less (P < 0.0001) for EM at 230.54 µGy (range, 51-660 µGy; SD, 0.17 µGy) compared with 690.27 µGy (range, 200-2310 µGy; SD, 0.52 µGy) for FH. There were 2 misplaced drill bits in FH and 3 in EM. This was not statistically significant (P = 0.888). CONCLUSIONS: The electromagnetic targeting device (Sureshot) significantly reduced radiation exposure during placement of distal interlocking screws, without sacrificing operative time, and was equivalent in accuracy when compared with the FH technique. LEVEL OF EVIDENCE: Therapeutic level II.

Genetic differences between Asian and Caucasian chronic lymphocytic leukemia.

Chronic lymphocytic leukemia (CLL) is a common hematological malignancy in Western countries. However, this disease is very rare in Asian countries. It is not clear whether the mechanisms of development of CLL in Caucasians and Asians are the same. We compared genetic abnormalities in Asian and Caucasian CLL using 250k GeneChip arrays. Both Asian and Caucasian CLL had four common genetic abnormalities: deletion of 13q14.3, trisomy 12, abnormalities of ATM (11q) and abnormalities of 17p. Interestingly, trisomy 12 and deletion of 13q14.3 were mutually exclusive in both groups. We also found that deletions of miR 34b/34c (11q), caspase 1/4/5 (11q), Rb1 (13q) and DLC1 (8p) are common in both ethnic groups. Asian CLL more frequently had gain of 3q and 18q. These suggest that classic genomic changes in the Asian and Caucasina CLL are same. Further, we found amplification of IRF4 and deletion of the SP140/SP100 genes; these genes have been reported as CLL-associated genes by previous genome-wide-association study. We have found classic genomic abnormalities in Asian CLL as well as novel genomic alteration in CLL.