Decency, honor, integrity, and the law

In its guidelines for hand care professionals, the American Society for Surgery of the Hand has set the following criteria as guidelines for the ethical hand surgeon in the 21st century: decency, honor, and integrity. This article reviews these criteria in detail, relates how they apply in practice, and describes how they interact with state and federal law in both legislative and judicial aspects. Matters pertaining to informed consent, privacy issues, patient autonomy, shared decision making, and conflict of interest are described, and recent developments in this area are examined. Are hand surgeons ready for an enforceable system of ethics to be handed down by the ASSH or by the government?     

Molecular aspects of bacterial adhesion, colonization, and development of infections associated with biomaterials

Staphylococcus aureus and coagulase-negative staphylococci of species commonly isolated from biomaterial-associated infections commonly express fibronectin-binding surface proteins and the ability to interact with collagen. These findings, as well as the ability of coagulase-negative staphylococci to produce surface slime or capsular material, are presented as alternative models for how biofilms develop on biomaterial surfaces. Further knowledge of how bacteria and eukaryotic cells interact with various biomaterials will stimulate the development of better tissue implant devices to avoid biomaterial-associated infections.     

Oxygen sensing,anaesthesia and critical care: a narrative review

In 2019, the scientists who discovered how cells sense and adapt to oxygen availability were awarded the Nobel Prize. This elegant sensing pathway is conserved throughout evolution, and it underpins the physiology and pathology that we, as clinicians in anaesthesia and critical care, encounter on a daily basis. The purpose of this review is to bring hypoxia-inducible factor, and the oxygen-sensing pathway as a whole, to the wider clinical community. We describe how this unifying mechanism was discovered, and how it orchestrates diverse changes such as erythropoiesis, ventilatory acclimatisation, pulmonary vascular remodelling and altered metabolism. We explore the lessons learnt from genetic disorders of oxygen sensing, and the wider implications in evolution of all animal species, including our own. Finally, we explain how this pathway is relevant to our clinical practice, and how it is being manipulated in new treatments for conditions such as cancer, anaemia and pulmonary hypertension.     

The labrum: structure, function, and injury with femoro-acetabular impingement

Background

The recognition of the importance of femoro-acetabular impingement (FAI) as a potential cause of hip pain has been stimulated by major efforts to salvage hip joints by reconstruction to prevent or delay the need for replacement. A previous review addressed the nature of FAI, the various types, and how to make the diagnosis. When FAI occurs, the structure between the femur and acetabular rim, the labrum, is initially impinged upon and subsequently injured.

Method

Injury to the labrum should be recognized when treating the osseous causes of FAI. Preserving or recovering labral function, enhancing hip stability and protecting the articular surface, is critical to restoring the hip to normal or near-normal mechanical and physiologic function. The present review collected the varied essential information about the labrum in a succinct manner, independent of treatment algorithms.

Results/conclusion

Advanced knowledge of the labrum is presented, including the anatomy, circulation, histology, embryology, and neurology, as well as how the labrum tears, the types of tears, and how to make the diagnosis. The advantages and limitations of diagnostic magnetic resonance techniques are discussed, including magnetic resonance imaging (MRI), indirect magnetic resonance arthrography (i-MRA), and direct magnetic resonance arthrography (d-MRA). The review recognizes the complexity of the labrum and provides a greater understanding of how the labrum is capable of stabilizing the joint and protecting the articular surface of the hip. This information will act as a guide in developing treatment plans when treating FAI.     

Myocardial temperature management during aortic clamping for cardiac surgery. Protection, preoccupation, and perspective

The temperature of the heart and the duration of aortic clamping are the two aspects of myocardial protection that receive the greatest amount of attention during many cardiac operations. Preoccupation with profound cardiac cooling has given rise to the development of multiple devices to keep the heart as cold as possible. This report is written to put into perspective the roles of hypothermia and aortic clamping in the overall strategy of myocardial protection. I also wish to (1) suggest that intraoperative myocardial damage is determined more by "how the heart is protected" than by "how long the aorta is clamped or how cold the heart is made," (2) question whether the benefits of deep cardiac hypothermia are sufficient to offset the monetary costs and morbidity that may result from its use, and (3) suggest that using all the measures currently available to prevent, avoid, and reverse ischemic and reperfusion damage is preferable to preoccupation with profound cardiac cooling.     

Defining,measuring, and improving value in spine care

This chapter discusses how to measure and improve spine care outcomes and costs. Today’s commonly used outcome metrics, such as readmission and complication rates, are actually process and quality metrics. They are not the outcomes, such as improvement in pain and mobility, that patients expect to enjoy from being treated for spine pain. Similarly, existing cost measurements of spine care, derived from ratios of cost-to-charges or relative value units, are inaccurate and do not track actual resources used to treat spine care patients over complete treatment cycles. We document how to improve the value of spine care by adopting patient reported outcomes measures that can be collected in a standardized way. Similarly, more accurate cost measurement can be achieved by implementing Time-Driven Activity-Based Costing, an approach that helps clinicians identify opportunities to reduce the cost of delivering spine care without adversely affecting, and often improving, patient outcomes.     

Molecular Aspects of Bacterial Adhesion,Colonization, and Development of Infections Associated with Biomaterials

Staphylococcus aureus und coagulase-negative staphylococci of species commonly isolated from biomaterial-associated infections commonly express fibronectin-binding surface proteins and the ability to interact with collagen. These findings, us well us the ability of coagulase-negative staphylococci to produce surface slime or capsular material. are presented as alternative models for how biofilms develop on biomaterial surfaces. Further knowledge of how bacteria und eukaryotic cells interact with various biomaterials materials bill stimulate the development of better implant devices to avoid biomaterial-associated infections     

My first year in academic practice: what I learned, what I wish I knew, what I would do differently

Joining a practice for the first time after training, whether in academia or the private sector, is fraught with challenges and a learning curve. Postgraduate education has not sufficiently taught anyone how to manage the nuances of this new arena or how to become successful. Success is not solely a function measured by reportable taxable income. Respect by colleagues, patients, partners, and staff is just as important, if not more so. The financial attributes will be realized if the tangibles and intangibles discussed are appropriately executed in the correct environment. This article will discuss what to be cognizant of during the first years in academic practice and how to build a foundation for success.     

Views of American Pediatric Surgeons on Diversity,Equity, and Inclusion

IntroductionDiversity, Equity, and Inclusion (DEI) are concepts common in surgery. However, these can be difficult to define, and what constitutes DEI can be vague. Closing this knowledge gap, particularly within pediatric surgery, would be helpful to understand the views and needs of current surgeons.Methods1558 APSA members were sent an anonymous survey, of which 423 (27%) responded. Respondents were asked about their demographics, views on what constitutes diversity as well as questions on how DEI is handled within APSA and definitions of common DEI terms.ResultsOf 11 possible diversity measures, members agreed that a median of 9 (IQR 7–11) counted towards diversity. The most common being race and ethnicity (98%), gender (96%), sexual orientation (93%), religion (92%), age (91%), and disability (90%). On a 5-point Likert scale, the median response was 4 or greater on questions regarding how APSA handles issues related to DEI. However, members who identify as black were less likely to score in favor of APSA, and members identifying as women were more likely to rank higher importance of DEI initiatives. We also captured subjective responses on DEI terminology.ConclusionRespondents had broad definitions of diversity. There is support for further DEI initiatives and how APSA handles DEI, however this perception differs based on identities. There is significant variability in beliefs and views regarding DEI definitions and understanding this is helpful for the organization moving forward.Level of EvidenceIV.Type of StudyOriginal Research.     

Neural stem cells, neural progenitors, and neurotrophic factors

Neural stem cells (NSCs) have been proposed as a promising cellular source for the treatment of diseases in nervous systems. NSCs can self-renew and generate major cell types of the mammalian central nervous system throughout adulthood. NSCs exist not only in the embryo, but also in the adult brain neurogenic region: the subventricular zone (SVZ) of the lateral ventricle. Embryonic stem (ES) cells acquire NSC identity with a default mechanism. Under the regulations of leukemia inhibitory factor (LIF) and fibroblast growth factors, the NSCs then become neural progenitors. Neurotrophic and differentiation factors that regulate gene expression for controlling neural cell fate and function determine the differentiation of neural progenitors in the developing mammalian brain. For clinical application of NSCs in neurodegenerative disorders and damaged neurons, there are several critical problems that remain to be resolved: 1) how to obtain enough NSCs from reliable sources for autologous transplantation; 2) how to regulate neural plasticity of different adult stem cells; 3) how to control differentiation of NSCs in the adult nervous system. In order to understand the mechanisms that control NSC differentiation and behavior, we review the ontogeny of NSCs and other stem cell plasticity of neuronal differentiation. The role of NSCs and their regulation by neurotrophic factors in CNS development are also reviewed.     

Time pressure,work-related spousal support seeking,and relationship satisfaction: Spillover and crossover effects among dual-earner couples

The present study examined how time pressure at work is transmitted to the home domain and how it affects individuals' (spillover) as well as their partners' relationship satisfaction (crossover). We examined the role of work-related spousal support seeking and proposed that it serves as a mediator of the spillover as well as the crossover process. We further explored whether the proposed spillover-crossover process is gender-contingent. Using a sample of 308 dual-earner couples, we found support for a positive link between time pressure at work and spousal support seeking. As hypothesised, spousal support seeking served also as a crossover mechanism. However, distinct spillover and crossover processes were found for men and women. These findings not only point to a new spillover and crossover mechanism but also highlight gender-specific patterns in the role of support seeking. As this coping strategy is feasible when job stressors are high, it should be considered a part of stress management trainings and organizational practices.     

Multi-modal prehabilitation: addressing the why,when, what,how, who and where next?

Just as there is growing interest in enhancing recovery after surgery, prehabilitation is becoming a recognised means of preparing the patient physically for their operation and/or subsequent treatment. Exercise training is an important stimulus for improving low cardiovascular fitness and preserving lean muscle mass, which are critical factors in how well the patient recovers from surgery. Despite the usual focus on exercise, it is important to recognise the contribution of nutritional optimisation and psychological wellbeing for both the adherence and the response to the physical training stimulus. This article reviews the importance of a multi-modal approach to prehabilitation in order to maximise its impact in the pre-surgical period, as well as critical future steps in its development and integration in the healthcare system.     

Julia Pastrana,the “extraordinary lady”

Julia Pastrana was a Mexican woman whose “extraordinary” appearance led to her being displayed throughout Europe and America, first as a freak, then as a specimen. Recently, she was reburied in her birthplace. This essay considers the ways that Pastrana's display both reinforces and challenges the lines between the self and other, human and non-human, ordinary and extraordinary that such spectacles rely upon. It further suggests how discursive systems, such as race, gender, normativity, and humanness intertwine in the social practices that constitute them. By analyzing how Pastrana's display and recent repatriation and burial in Sinaloa invest her body with different meanings, this essay traces more complexly the processes that socially mark human bodies in order to reveal and explicate the inner workings of representational systems, such as race, gender, ethnicity, and disability.     

Peripheral nerve injuries,pain, and neuroplasticity

Introduction

Peripheral nerve injuries (PNIs) cause both structural and functional brain changes that may be associated with significant sensorimotor abnormalities and pain.

Disaster preparedness, triage, and surge capacity for hospital definitive care areas: optimizing outcomes when demands exceed resources

Disaster planning must anticipate how demands imposed by a disaster reconcile with the capacity of the treating facility. Resources must be organized before an event so that they are optimally used to treat as many victims as possible, as well as to avoid overwhelming available resources.     

Chemical,biological, radiological and nuclear major incidents

Chemical, biological, radiological and nuclear (CBRN) incidents have the potential to be catastrophic if they occur on a society that is not prepared for them. It is important to know how to make plans to mitigate against such events as well as to manage a scene where CBRN agents are present. CBRN agents are potentially hazardous to responders at both a scene and many miles away in a medical treatment facility. An understanding of the risks and the ways to mitigate these is paramount. Early recognition and treatment with specific antidotes can have a profound effect on both morbidity and mortality of those affected.     

Medical consensus,guidelines, and position papers: A policy for the ECFS

The terms consensus, guideline and position paper are sometimes employed as if they were interchangeable, but the purpose of such documents and the robustness of advice vary as the evidence base does not have the same depth in each. The Board of the European Cystic Fibrosis Society deemed it to be helpful to provide a short commentary on the definition of these terms, on their interconnections and on how ECFS considers them in documents endorsed by the society.     

The von Hippel-Lindau gene, kidney cancer, and oxygen sensing

Recent studies of a relatively rare hereditary cancer syndrome, von Hippel-Lindau (VHL) disease, have shed new light on the molecular pathogenesis of kidney cancer and, perhaps more important, on how mammalian cells sense and respond to changes in oxygen availability. This knowledge is already translating into new therapeutic targets for kidney cancer as well as for multiple conditions, such as myocardial infarction and stroke, in which ischemia plays a pathogenic role. This review summarizes the current knowledge of the molecular pathogenesis of von Hippel-Lindau disease and the role of the VHL gene product (pVHL) in kidney cancer and the mammalian oxygen sensing pathway.