Kimberly J. Templeton

Measuring the Attitudes and Impact of the Eighty-Hour Workweek Rules on Orthopaedic Surgery Residents

BACKGROUND The literature on graduate medical education contains anecdotal reports of some effects of the new eighty-hour workweek on the attitudes and performance of residents. However, there are relatively few studies detailing the attitudes of large numbers of residents in a particular surgical specialty toward the new requirements. METHODS Between July and November 2004, a survey created by the Academic Advocacy Committee of the American Academy of Orthopaedic Surgeons was distributed by mail, fax, and e-mail to a total of 4207 orthopaedic residents at the postgraduate year-1 through year-6 levels of training. The survey responses were tabulated electronically, and the results were recorded. RESULTS The survey response rate was 13.2% (554 residents). Sixty-eight percent (337) of the 495 respondents whose postgraduate-year level was known were at the postgraduate year-4 level or higher. Attitudes concerning the duty rules were mixed. Twenty-three percent of the 554 respondents thought that eighty hours constituted an appropriate number of duty hours per week; 41% believed that eighty hours were too many, and 34% thought that eighty hours were not sufficient. Thirty-three percent of the respondents had worked greater than eighty hours during at least a single one-week period since the new rules were implemented; this occurred more commonly among the postgraduate year-3 and more junior residents. Orthopaedic trauma residents had the most difficulty adhering to the new duty-hour restrictions. Eighty-two percent of the respondents indicated that their residency programs have been forced to make changes to their call schedules or to hire ancillary staff to address the rules. The use of physician assistants, night-float systems, and so-called home-call assignments were the most common strategies used to achieve compliance. CONCLUSION Resident attitudes toward the work rules are mixed. The rules have forced residency programs to restructure. Junior residents have more favorable attitudes toward the new standards than do senior residents. Self-reporting of duty hours is the most common method of monitoring in orthopaedic training programs. Such systems allow ample opportunity for inaccuracies in the measurement of hours worked. Although residents report an improved quality of life as a result of these new rules, the attitude that the quality of training is diminished persists.

Effect of 25-hydroxyvitamin D3 and 1 α,25 dihydroxyvitamin D3 on differentiation and apoptosis of human osteosarcoma cell lines

Osteosarcoma (OS) is a malignant bone tumor predominantly affecting children and adolescents. OS has a 60% survival rate with current treatments; hence, there is a need to identify novel adjuncts to chemotherapeutic regimens. In this pilot study, we investigated the dose‐response to 1α,25‐dihdroxyvitamin D3 (1,α 25(OH)2D3) and 25‐hydroxyvitamin D3 (25(OH)D3) by human OS cell lines, SaOS‐2, and 143B. We hypothesized that 1,α 25(OH)2D3 and 25(OH)D3 would stimulate differentiation and induce apoptosis in OS cells in a dose‐dependent manner. Human OS cell lines, SaOS‐2, and 143B, were treated with 1,α 25(OH)2D3 or 25(OH)D3 or an ethanol control, respectively, at concentrations ranging from 1 to 1,000 nM. Ki67 (a marker of cellular proliferation) immunocytochemistry revealed no significant changes in the expression of Ki‐67 or MIB‐1 in 1α,25(OH)2D3 or 25(OH)D3 treated SaOS‐2 or 143B cells. Both control and 1α,25(OH)2D3 treated SaOS‐2 and 143B cells expressed vitamin D receptor (VDR). Markers of osteoblastic differentiation in 143B cells and SaOS‐2 cells were induced by both 25(OH)D3 and 1α,25(OH)2D, and evident by increases in alkaline phosphatase (ALP) activity, osteocalcin (OCN) mRNA expression, and mineralization of extra‐cellular matrix (ECM) by alizarin red staining. An increasing trend in apoptosis in response to 25(OH)D3, in both SaOS‐2 and 143B cells was detected by terminal deoxynucleotidyl transferase (TdT)‐mediated dUTP nick end labeling (TUNEL) staining. With 1α,25(OH)2D3 treatment, apoptosis was evident at higher concentrations only. These preliminary findings suggest that OS cells express VDR and respond to 25(OH)D3 and 1α,25(OH)2D3 by undergoing differentiation and apoptosis.

The American Academy of Orthopaedic Surgeons Evidence-Based Guideline on Management of Hip Fractures in the Elderly.

The AAOS Evidence-Based Guideline on Management of Hip Fractures in the Elderly includes both diagnosis and treatment. This clinical practice guideline has been endorsed by the Orthopaedic Trauma Association (OTA), the American Academy of Physical Medicine and Rehabilitation (AAPM&R), the American Society for Bone and Mineral Research (ASBMR), the United States Bone and Joint Initiative, the Hip Society, the American Association of Clinical Endocrinologists, the Orthopaedic Rehabilitation Association (ORA), and the American Geriatrics Society (AGS). This brief summary of the AAOS Clinical Practice Guideline contains a list of the recommendations and the rating of strength based on the quality of the supporting evidence. Discussion of how each recommendation was developed and the complete evidence report are contained in the full guideline at www.aaos.org/guidelines. ### ADVANCED IMAGING Moderate evidence supports MRI as the advanced imaging of choice for diagnosis of presumed hip fracture not apparent on initial radiographs. Strength of Recommendation: Moderate ★★★☆ ### PERIOPERATIVE REGIONAL ANALGESIA Strong evidence supports regional analgesia to improve preoperative pain control in patients with hip fracture. …

Advancing sex and gender competency in medicine: sex & gender women's health collaborative

Research conducted to date has deepened our understanding of sex and gender differences in the etiology, diagnosis, treatment, and outcomes for many conditions that affect both women and men. The Sex and Gender Women’s Health Collaborative (SGWHC) is supported by the coordinated efforts of our founding partners: the American Medical Women’s Association, the American College of Women’s Health Physicians and Society for Women’s Health Research to address the gaps in medical education with regard to sex and gender competency in the care of women. The SGWHC initiated and continues to build a novel digital resource library of sex and gender specific materials to be adopted and adapted into medical education and clinical practice, residing @ http://www.sgwhc.org. This article presents a case for the inclusion of sex and gender focused content into medical curricula and describes a means for students, faculty, and practitioners to access a centralized, interactive repository for these resources.

Beyond the decade: Strategic priorities to reduce the burden of musculoskeletal disease

In the U.S., direct expenditures involving health-care costs and indirect expenditures involving lost wages of persons with musculoskeletal diseases have been estimated to total

Vitamin D Receptor, Retinoid X Receptor, Ki-67, Survivin, and Ezrin Expression in Canine Osteosarcoma

950 billion, or 7.4% percent of the U.S. gross national product, in 2004-20061. Despite this enormous financial burden, in addition to the personal and societal impact, musculoskeletal research represents less than 2% of the National Institutes of Health (NIH) budget2. This disparity between the burden of these diseases and the investment in research to develop improved preventive and treatment strategies for them is noted in every region of the world and has been a major impetus for the global Bone and Joint Decade movement. After ten years, it is important to undertake a retrospective analysis of what has been accomplished and what remains to be done with this program. The U.S. Bone and Joint Initiative (USBJI, previously called the U.S. Bone and Joint Decade, the National Action Network of the global Bone and Joint Decade) conducted a strategic planning process to determine what the organization is best positioned to accomplish, to assess how it can serve its mission in the future, and to set priorities “beyond the decade.” This was accomplished by six task groups (Arthritis, Bone Health and Osteoporosis, Pediatric Musculoskeletal Conditions, Spinal Disorders and Low Back Pain, Trauma and Injury, and Research). The following is a compilation of the priorities identified by each group. ### Priority Area 1.1: Public Education and Patient Empowerment There needs to be increased public recognition of the benefits of prevention, early diagnosis, and treatment of arthritis, including the importance of positive health behaviors. By the year 2020, the number of persons who attend or participate in arthritis health promotion activities such as public education, patient empowerment, arthritis self-management, exercise, and other programs should increase by 50%. To accomplish this ambitious task, it will be …

Clinicopathologic correlation of vitamin D receptor expression with retinoid X receptor and MIB-1 expression in primary and metastatic osteosarcoma.

Canine osteosarcoma (OS) is an aggressive malignant bone tumor. Prognosis is primarily determined by clinical parameters. Vitamin D has been postulated as a novel therapeutic option for many malignancies. Upon activation, vitamin D receptors (VDRs) combine with retinoid receptor (RXR) forming a heterodimer initiating a cascade of events. Vitamin Ds antineoplastic activity and its mechanism of action in OS remain to be clearly established. Expression of VDR, RXR, Ki-67, survivin, and ezrin was studied in 33 archived, canine OS specimens. VDR, RXR, survivin, and ezrin were expressed in the majority of cases. There was no statistically significant difference in VDR expression in relationship with tumor grade, type, or locations or animal breed, age, and/or sex. No significant association (p = 0.316) between tumor grade and Ki-67 expression was found; in particular, no difference in Ki-67 expression between grades 2 and 3 OSs was found, while a negative correlation was noted between Ki-67 and VDR expression (ρ = −0.466), a positive correlation between survivin and RXR expression was found (p = 0.374). A significant relationship exists between VDR and RXR expression in OSs and proliferative/apoptosis markers. These results establish a foundation for elucidating mechanisms by which vitamin D induces antineoplastic activity in OS.

Free filet leg flap.

Vitamin D, in addition to its effects on bone, is important in cell cycle regulation. Vitamin D receptor (VDR) has been identified in breast, prostate, and colon cancers, as well as in canine and human osteosarcoma (OS) cell lines; however, it has not been well investigated in human OS-archived specimens. We correlated VDR, retinoid X receptor (RXR), and MIB-1 (Ki-67) expression in 110 archived OS cases with several clinicopathologic parameters including patients age, sex, tumor location, tumor grade, and type and metastatic status. The expression of VDR and RXR was identified in human OS tissue obtained from primary and metastatic OS archival tissue. No statistically significant difference was found in VDR expression in relation with tumor grade, type, age, sex, or location. The expression of RXR was highest in higher-grade (P = .0006) and metastatic tumors but remained unchanged when correlated with tumor type, age, sex, or location. The expression of MIB-1 was statistically elevated in higher-grade tumors (P = .001), patients 25 years or younger (P = .04), tumors located in extremities (P = .005), and metastatic lesions, but was not impacted by tumor type or patients sex. Proliferative activity was significantly reduced after treatment, as the mean MIB-1 expression dropped from 11% in primary biopsy samples to 6% in resection specimens. There appears to be a relationship between proliferative tumor activity and tumor grade, location, and metastasis. Additional studies on the analysis of the effects of vitamin D and RXR on OS proliferation, apoptosis, and differentiation are critical to further evaluate their potential role in OS treatment.

Sex and Gender Medical Education Summit: a roadmap for curricular innovation

With extensive loss of local soft tissues after resection of a sarcoma, standard closure may not be possible. The large operative defect in this instance may necessitate a free tissue transfer. Use of a vascularized tissue transfer from the leg of the amputated extremity of a patient to close a hemipelvectomy defect is described.

A 29-year-old man with buttock pain.

The Sex and Gender Medical Education Summit: a roadmap for curricular innovation was a collaborative initiative of the American Medical Womens Association, Laura W. Bush Institute for Women’s Health, Mayo Clinic, and Society for Womens Health Research (www.sgbmeducationsummit.com). It was held on October 18–19, 2015 to provide a unique venue for collaboration among nationally and internationally renowned experts in developing a roadmap for the incorporation of sex and gender based concepts into medical education curricula. The Summit engaged 148 in-person attendees for the 1 1/2-day program. Pre- and post-Summit surveys assessed the impact of the Summit, and workshop discussions provided a framework for informal consensus building. Sixty-one percent of attendees indicated that the Summit had increased their awareness of the importance of sex and gender specific medicine. Other comments indicate that the Summit had a significant impact for motivating a call to action among attendees and provided resources to initiate change in curricula within their home institutions. These educational efforts will help to ensure a sex and gender basis for delivery of health care in the future.