Glucose metabolism is altered in injured and healing tendons. However, the mechanism by which the glucose metabolism is involved in the pathogenesis of tendon healing process remains unclear. Injured ...tendons do not completely heal, and often induce fibrous scar and chondroid lesion. Because previous studies have shown that tendon progenitors play roles in tendon repair, we asked whether connective tissue progenitors appearing in injured tendons alter glucose metabolism during tendon healing process. We isolated connective tissue progenitors from the human injured tendons, obtained at the time of primary surgical repair of rupture or laceration. We first characterized the change in glucose metabolism by metabolomics analysis using 1,2-13C-glucose using the cells isolated from the lacerated flexor tendon. The flux of glucose to the glycolysis pathway was increased in the connective tissue progenitors when they proceeded toward tenogenic and chondrogenic differentiation. The influx of glucose to the tricarboxylic acid (TCA) cycle and biosynthesis of amino acids from the intermediates of the TCA cycle were strongly stimulated toward chondrogenic differentiation. When we treated the cultures with 2-deoxy-D-glucose (2DG), an inhibitor of glycolysis, 2DG inhibited chondrogenesis as characterized by accumulation of mucopolysaccharides and expression of AGGRECAN. Interestingly, 2DG strongly stimulated expression of tenogenic transcription factor genes, SCLERAXIS and MOHAWK under both chondrogenic and tenogenic differentiation conditions. The findings suggest that control of glucose metabolism is beneficial for tenogenic differentiation of connective tissue progenitors.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Patient satisfaction surveys are important measures of the patient experience that provide data for quality improvement. The purpose of this study was to establish the response rate and the factors ...associated with the completion of the Press Ganey (PG) Ambulatory Surgery Survey (PGAS) in patients who underwent ambulatory upper-extremity surgical procedures.
A prospective orthopaedic registry at a single academic ambulatory surgical center was retrospectively reviewed for patients who underwent an upper-extremity surgical procedure from 2015 to 2019. The institutional PG database was queried to determine the patients who completed the PGAS postoperatively. The response rate was calculated, and baseline characteristics and patient-reported outcome measures were compared between responders and nonresponders.
Of the 1,489 patients included, 201 (13.5%) were responders and 1,288 (86.5%) were nonresponders. Differences existed in baseline characteristics between groups, with responders being significantly older (p = 0.004) and having significantly higher proportions of White race (p < 0.001), college education (p = 0.011), employment (p = 0.005), marriage (p = 0.006), and higher income earners (p < 0.001). Responders had significantly better baseline Patient-Reported Outcomes Measurement Information System scores across multiple domains (p < 0.05), but these differences were not clinically meaningful.
PGAS response rates were low (13.5%), and differences between responders and nonresponders may be utilized by hospitals to target feedback from underrepresented patient populations. Surgeons, policymakers, and health-care administrators should use caution with the interpretation of PGAS results because responders may not be representative of all patients.
Background:
Tendon injuries are common problems among athletes. Complete recovery of the mechanical structure and function of ruptured tendons is challenging. It has been demonstrated that ...upregulation of glycolysis and lactate production occurs in wounds, inflammation sites, and cancerous tumors, and these metabolic changes also control growth and differentiation of stem and progenitor cells. Similar metabolic changes have been reported in human healing tendons. In addition, lactate production has increased in progenitors isolated from injured tendons after treatment with IL-1β. It is thought that the metabolic changes play a role in tendon healing after injury.
Hypothesis:
Glucose metabolism is altered during tendon injury and healing, and modulation of this altered metabolism improves tendon repair.
Study Design:
Controlled laboratory study.
Methods:
The authors used the tendon injury model involving a complete incision of the Achilles tendon in C57BL/6J female mice and studied alterations of glucose metabolism in injured tendons with U-13Cglucose and metabolomics analysis 1 and 4 weeks after surgery. They also examined the effects of dichloroacetate (DCA; an indirect lactate synthesis inhibitor) treatment on the recovery of structure and mechanical properties of injured tendons 4 weeks after surgery in the same mouse model.
Results:
Significant changes in glucose metabolism in tendons after injury surgery were detected. 13C enrichment of metabolites and intermediates, flux through glycolysis, and lactate synthesis, as well as tricarboxylic acid cycle activity, were acutely increased 1 week after injury. Increased glycolysis and lactate generation were also found 4 weeks after injury. DCA-treated injured tendons showed decreased cross-sectional area and higher values of modulus, maximum stress, and maximum force when compared with vehicle-treated injured tendons. Improved alignment of the collagen fibers was also observed in the DCA group. Furthermore, DCA treatment reduced mucoid accumulation and ectopic calcification in injured tendons.
Conclusion:
The findings indicate that injured tendons acutely increase glycolysis and lactate synthesis after injury and that the inhibition of lactate synthesis by DCA is beneficial for tendon healing.
Clinical Relevance:
Changing metabolism in injured tendons may be a therapeutic target for tendon repair.
Background:
The objectives of this study were to determine the baseline patient characteristics associated with preoperative opioid use and to establish whether preoperative opioid use is associated ...with baseline patient-reported outcome measures in patients undergoing common hand surgeries.
Methods:
Patients undergoing common hand surgeries from 2015 to 2018 were retrospectively reviewed from a prospective orthopedic registry at a single academic institution. Medical records were reviewed to determine whether patients were opioid users versus nonusers. On enrollment in the registry, patients completed 6 Patient-Reported Outcomes Measurement Information System (PROMIS) domains (Physical Function, Pain Interference, Fatigue, Social Satisfaction, Anxiety, and Depression), the Brief Michigan Hand Questionnaire (BMHQ), a surgical expectations questionnaire, and Numeric Pain Scale (NPS). Statistical analysis included multivariable regression to determine whether preoperative opioid use was associated with patient characteristics and preoperative scores on patient-reported outcome measures.
Results:
After controlling for covariates, an analysis of 353 patients (opioid users, n = 122; nonusers, n = 231) showed that preoperative opioid use was associated with higher American Society of Anesthesiologists class (odds ratio OR, 2.88), current smoking (OR, 1.91), and lower body mass index (OR, 0.95). Preoperative opioid use was also associated with significantly worse baseline PROMIS scores across 6 domains, lower BMHQ scores, and NPS hand scores.
Conclusions:
Preoperative opioid use is common in hand surgery patients with a rate of 35%. Preoperative opioid use is associated with multiple baseline patient characteristics and is predictive of worse baseline scores on patient-reported outcome measures. Future studies should determine whether such associations persist in the postoperative setting between opioid users and nonusers.
Opioid overprescribing has caused a substantial increase in opioid related deaths and billions of dollars in additional healthcare costs. Orthopaedic surgeons commonly prescribe opioids in the ...perioperative period; however, research has shown preoperative opioid use may be associated with worse postoperative outcomes. Despite this body of evidence, there are few studies investigating the association between preoperative opioid use and two-year outcomes after hand surgery.
This study evaluated two-year postoperative patient-reported outcomes in patients who used opioids prior to hand surgery, and those who did not. Patients completed pre and postoperative questionnaires including Patient-Reported Outcomes Measurement Information System (PROMIS) domains, the Brief Michigan Hand Questionnaire (BMHQ), and other questionnaires related to pain, function, and satisfaction. 342 patients undergoing upper-extremity surgery were enrolled into a prospective orthopaedic surgery outcome registry, and 69.9% completed the follow-up surveys. Preoperative opioid use and its association to patient outcome scores was analyzed through bivariate analysis. Significant associations were further tested by multivariable analysis to determine independent predictors.
Preoperative opioid use was associated with worse two-year PROMIS Fatigue (p < .01), PROMIS Anxiety (p < .01), PROMIS Depression (p < .01), SSQ-8 (p = .01), BMHQ (p = .01), NPS Hand (p < .01) and MODEMS met expectations (p = .03). No significant differences were observed in patient-reported outcome change scores. Multivariable analysis demonstrated that preoperative opioid use was predictive of worse two-year PROMIS Fatigue (p < .01), PROMIS Anxiety (p < .01), PROMIS Depression (p = .02), BMHQ (p = .01), SSQ-8 (p < .01), NPS Hand (p = .02) and MODEMS met expectations (p < .01).
Preoperative opioid use was associated with worse patient-reported outcomes two years after elective hand surgery. There was no significant difference in the improvement from baseline between the two groups. Clinically significant differences were observed in follow-up PROMIS Anxiety, BMHQ and NPS – Hand scores. Clinically significant change scores were noted in both groups for PROMIS PF, PROMIS PI, PROMIS SS, BMHQ, and NPS – Hand.
Introduction Studies have shown a link between patients' preoperative expectations and their postoperative satisfaction. However, limited studies exist concerning patient factors associated with ...higher preoperative expectations in the hand surgery population. This study analyzed preoperative expectation scores of patients undergoing hand surgery and aimed to determine associated patient characteristics.
Materials and Methods A total of 418 elective hand surgery patients aged 15 years and older enrolled in a prospectively collected orthopaedic registry from June 2015 to December 2018 were analyzed. Patients were administered preoperative questionnaires including six Patient-Reported Outcome Measurement Information System domains and other activity and pain scales. Expectation scores were measured using the six domains of the Musculoskeletal Outcomes Data Evaluation and Management System expectations questionnaire. Bivariate and multivariable analyses were conducted to identify independent predictors of higher expectations.
Results Overall, patients had high expectations (≥ 80.0) of their hand surgery. Higher mean expectation scores were seen with females, college graduates, better baseline health status, and fewer prior hand surgeries (p < 0.05 for all). No significant associations were found among the Common Procedural Terminology codes and expectations. Multivariable analysis confirmed that college degree (p = 0.023) and less pain (p = 0.008) were predictive of higher baseline expectations.
Conclusion In sum, more educated patients with less pain at baseline and better baseline health status have higher expectations of their hand surgery. Hand surgeons can use these results to help focus their preoperative counseling and expectation management.
The healthcare industry is shifting its focus from traditional clinical outcome measures to patient satisfaction metrics. This change has caused orthopaedic surgeons to become increasingly interested ...in factors influencing patient satisfaction, which would allow them to potentially modify these factors in an effort to increase postoperative satisfaction. The objective of this study was to identify factors associated with patient satisfaction two weeks following extremity orthopaedic surgery.
Patients completed questionnaires preoperatively to assess demographics, activity, pain, expectations, and Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive testing for Physical Function, Pain Interference, Social Satisfaction, Depression, Anxiety, and Fatigue. Two weeks after their operation, patients completed the same questionnaires in addition to an Improvement Survey and Met Expectations. Satisfaction was assessed with the Surgical Satisfaction Questionnaire.
Greater surgical satisfaction two weeks following orthopaedic surgery was associated with higher education, alcohol use, better scores on all PROMIS domains at baseline and two weeks, greater activity levels at baseline and two weeks, less bodily pain at baseline and two weeks, less pain in the surgical site at two weeks, greater met expectations, and greater improvement (p < 0.05).
This study provides important information about patient satisfaction two weeks after orthopaedic surgery.
Introduction: We sought to determine whether patient and surgical factors are associated with the Press Ganey Ambulatory Surgery Survey (PGAS) satisfaction scores in patients undergoing outpatient ...upper extremity procedures. Methods: A retrospective review of a single academic urban hospital's Press Ganey database was performed for patients undergoing upper extremity procedures. PGAS scores above an a priori threshold were considered satisfied. Logistic regression analyses for the PGAS Total and Provider Scores were performed to determine the predictors of patient satisfaction. Results: Of the 198 patients included, the mean age was 49.6 ± 17.1 years and 55% were men. For the Total Score, multivariable analysis showed significantly less satisfaction with continuous catheter peripheral brachial plexus nerve blocks (CC-PNBs) (odds ratio OR, 0.37; P = 0.008) and internet surveys (OR, 0.39; P = 0.007), but smokers had surprisingly more satisfaction (OR, 4.90; P = 0.016). For the Provider Score, a multivariable analysis showed less satisfaction with CC-PNBs (OR, 0.45; P = 0.035), internet surveys (OR, 0.46; P = 0.026), and geographic location (OR, 0.40; P = 0.005). Preoperative Patient-Reported Outcomes Measurement Information System scores were not associated with the PGAS scores. Discussion: Factors influencing satisfaction in patients undergoing upper extremity procedures may be modifiable (CC-PNBs and survey administration method) or nonmodifiable (geographic location) and may influence future reimbursement.
Injured tendons do not regain their native structure except at fetal or very young ages. Healing tendons often show mucoid degeneration involving accumulation of sulfated glycosaminoglycans (GAGs), ...but its etiology and molecular base have not been studied substantially. We hypothesized that quality and quantity of gene expression involving the synthesis of proteoglycans having sulfated GAGs are altered in injured tendons and that a reduction in synthesis of sulfated GAGs improves structural and functional recovery of injured tendons. C57BL6/j mice were subjected to Achilles tendon tenotomy surgery. The injured tendons accumulated sulfate proteoglycans as early as 1‐week postsurgery and continued so by 4‐week postsurgery. Transcriptome analysis revealed upregulation of a wide range of proteoglycan genes that have sulfated GAGs in the injured tendons 1 and 3 weeks postsurgery. Genes critical for enzymatic reaction of initiation and elongation of chondroitin sulfate GAG chains were also upregulated. After the surgery, mice were treated with the 2‐deoxy‐d‐glucose (2DG) that inhibits conversion of glucose to glucose‐6‐phosphate, an initial step of glucose metabolism as an energy source and precursors of monosaccharides of GAGs. The 2DG treatment reduced accumulation of sulfated proteoglycans, improved collagen fiber alignment, and reduced the cross‐sectional area of the injured tendons. The modulus of the 2DG‐treated groups was higher than that in the vehicle group, but not of statistical significance. Our findings suggest that mucoid degeneration in injured tendons may result from the upregulated expression of genes involved the synthesis of sulfate proteoglycans and can be inhibited by reduction of glucose utilization.
Feelings of imposter syndrome (inadequacy or incompetence) are common among physicians and are associated with diminished joy in practice. Identification of modifiable factors associated with ...feelings of imposter syndrome might inform strategies to ameliorate them. To this point, though, no such factors have been identified.
Are intolerance of uncertainty and confidence in problem-solving skills independently associated with feelings of imposter syndrome after accounting for other factors?
This survey-based experiment measured the relationship between feelings of imposter syndrome, intolerance of uncertainty, and confidence in problem-solving skills among musculoskeletal specialist surgeons. Approximately 200 surgeons who actively participate in the Science of Variation Group, a collaboration of mainly orthopaedic surgeons specializing in upper extremity illnesses primarily across Europe and North America, were invited to this survey-based experiment. One hundred two surgeons completed questionnaires measuring feelings of imposter syndrome (an adaptation of the Clance Imposter Phenomenon Scale), tolerance of uncertainty (the Intolerance of Uncertainty Scale-12), and confidence in problem-solving skills (the Personal Optimism and Self-Efficacy Optimism questionnaire), as well as basic demographics. The participants were characteristic of other Science of Variation Group experiments: the mean age was 52 ± 5 years, with 89% (91 of 102) being men, most self-reported White race (81% 83 of 102), largely subspecializing in hand and/or wrist surgery (73% 74 of 102), and with just over half of the group (54% 55 of 102) having greater than 11 years of experience. We sought to identify factors associated with greater feelings of imposter syndrome in a multivariable statistical model.
Accounting for potential confounding factors such as years of experience or supervision of trainees in the multivariable linear regression analysis, greater feelings of imposter syndrome were modestly associated with higher intolerance of uncertainty (regression coefficient β 0.34 95% confidence interval (CI) 0.16 to 0.51; p < 0.01) and with lower confidence in problem-solving skills (β -0.70 95% CI -1.0 to -0.35; p < 0.01).
The finding that feelings of imposter syndrome may be modestly to notably associated with modifiable factors, such as difficulty managing uncertainty and lack of confidence in problem-solving, spark coaching opportunities to support and sustain a surgeon's mindset, which may lead to increased comfort and joy at work.
Beginning with premedical coursework and throughout medical training and continuing medical education, future studies can address the impact of learning and practicing tactics that increase comfort with uncertainty and greater confidence in problem solving on limiting feelings of imposter syndrome.
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