Future considerations in the diagnosis and treatment of compressive neuropathies of the upper extremity

Compressive neuropathies of the upper extremity are among the most common conditions seen by hand surgeons. The diagnoses of carpal tunnel syndrome and cubital tunnel syndrome have traditionally been made by a combination of history, physical examination, and electrodiagnostic testing. However, findings can be nonspecific and electrodiagnostic testing is invasive for the patient. The diagnosis of compressive neuropathies continues to evolve as technology advances, and newer diagnostic modalities predominantly focus on preoperative diagnostic imaging with ultrasound and magnetic resonance imaging/neurography. With the advent of cheaper, faster, and less invasive imaging, the future may bring a paradigm shift away from electrophysiology as the gold standard for the preoperative diagnosis of compressive neuropathies. Intraoperative imaging of nerve health is an emerging concept that warrants further investigation, whereas postoperative imaging of nerve recovery with ultrasound and magnetic resonance imaging currently has a limited role because of nonspecific findings and potential for misinterpretation. Advances in surgical treatment of compressive neuropathies appear to center around the use of imaging for less invasive neurolysis techniques and other adjunctive treatments with nerve decompression. The management of failed peripheral nerve decompressions and recurrent compressive neuropathies remains challenging

Moving the needle: Directed intervention by the American Society for Surgery of the Hand is effective in encouraging diversity in expert panel composition

PURPOSE: Recent efforts have been made by the American Society for Surgery of the Hand to encourage female inclusion in expert panels. We hypothesized that female representation on expert panels has increased over the past decade and that a directed intervention by the American Society for Surgery of the Hand would be associated with an increased percentage of submissions with female panelists. METHODS: We performed a retrospective analysis of Instructional Course Lecture and Symposium submissions for the 2011 through 2021 American Society for Surgery of the Hand Annual Meetings. Authorship was reviewed, and the gender of the proposed authors was recorded. Additionally, the status of all-male panel was attributed to panels with no proposed female authors. Submissions were reviewed and compared with meeting programs to determine the status of accepted or rejected. Longitudinal analysis was performed to determine trends in the gender composition of expert panels. RESULTS: In total, 1,687 submissions were reviewed, including 1,323 Instructional Course Lectures and 364 Symposia. Female authorship constituted 18% of authorship (1,170/6,663), and lead authorship was similarly distributed, with 18% being female (296/1,687). Overall, female representation has increased steadily over the past decade, with females constituting 13% (43/332) and 20% (163/818) of the submitted authors in 2011 and 2020, respectively. Similarly, all-male panels declined from 74% (76/103) to 46% (85/185) of panels over the same timeframe. Most strikingly, a sharp increase in gender representation was observed with the directed intervention noted in the 2021 Call for Abstracts, resulting in an increase in female authorship to 26% (295/1,124) and a decline in all-male panels to 29% (70/241). CONCLUSIONS: Gender representation among hand surgery expert panels moved toward increased equity over the past decade, which has been aided by directed interventions. CLINICAL RELEVANCE: Career development and trainee decision making are impacted by gender representation; directed and intentional interventions by professional organizations are effective in encouraging greater equity and diversity within the field

Improving the normalization of complex interventions: measure development based on normalization process theory (NoMAD): study protocol

<b>Background</b> Understanding implementation processes is key to ensuring that complex interventions in healthcare are taken up in practice and thus maximize intended benefits for service provision and (ultimately) care to patients. Normalization Process Theory (NPT) provides a framework for understanding how a new intervention becomes part of normal practice. This study aims to develop and validate simple generic tools derived from NPT, to be used to improve the implementation of complex healthcare interventions.<p></p> <b>Objectives</b> The objectives of this study are to: develop a set of NPT-based measures and formatively evaluate their use for identifying implementation problems and monitoring progress; conduct preliminary evaluation of these measures across a range of interventions and contexts, and identify factors that affect this process; explore the utility of these measures for predicting outcomes; and develop an online users’ manual for the measures.<p></p> <b>Methods</b> A combination of qualitative (workshops, item development, user feedback, cognitive interviews) and quantitative (survey) methods will be used to develop NPT measures, and test the utility of the measures in six healthcare intervention settings.<p></p> <b>Discussion</b> The measures developed in the study will be available for use by those involved in planning, implementing, and evaluating complex interventions in healthcare and have the potential to enhance the chances of their implementation, leading to sustained changes in working practices

External validation of the FEAR index in borderline acetabular dysplasia

Background: Given the lack of established, externally validated criteria for the diagnosis of unstable hips, the Femoro-Epiphyseal Acetabular Roof (FEAR) index has been proposed as a useful tool for identifying hips with instability in the setting of borderline acetabular dysplasia. Purposes: To (1) determine the external performance of the FEAR index in identifying hips with a clinical diagnosis of instability in the setting of borderline dysplasia and (2) assess the performance of the FEAR index compared with acetabular inclination or physeal scar angle alone. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: The authors reviewed 176 patients with borderline acetabular dysplasia (lateral center-edge angle, 20°-25°). A positive FEAR index was defined as ≥5°. An alternative threshold ≥2° was also assessed. Significant instability was determined by the senior surgeon based on the combination of patient and radiographic features; unstable hips were treated with periacetabular osteotomy (with or without hip arthroscopy), and stable hips were treated with isolated hip arthroscopy. Results: Only 18% of borderline hips had a positive FEAR index. The ≥5° positive FEAR index threshold had a sensitivity of 33% (23/70) and specificity of 92% (98/106) in predicting the clinical diagnosis of instability. The ≥2° FEAR index threshold had a sensitivity of 39% (27/70) and specificity of 89% (94/106) in predicting the clinical diagnosis of instability. No alternative threshold for the FEAR index resulted in high levels of sensitivity and specificity. A threshold of -5° was required to reach an adequate sensitivity of 74%. The FEAR index remained a significant predictor of hip instability even after controlling for acetabular inclination (odds ratio, 1.12; Conclusion: In the current study, a positive FEAR index was generally indicative of the presence of clinical instability, but the FEAR index alone remained inadequate to fully define the instability of a given hip, as it demonstrated low sensitivity (only 33%) in the external validation. The FEAR index is best used in the context of other clinical and radiographic features

The development and analysis of tutorial dialogues in AutoTutor Lite

The goal of Intelligent Tutoring Systems (ITS) that interact in natural language is to emulate the benefits a well-trained human tutor provides to students, by interpreting student answers and appropriately responding to encourage elaboration. BRCA Gist is an ITS developed using AutoTutor Lite, a web-based version of AutoTutor. Fuzzy-Trace Theory theoretically motivated the development of BRCA Gist, which engages people in tutorial dialogues to teach them about genetic breast cancer risk. We describe an empirical method to create tutorial dialogues and fine-tune the calibration of BRCA Gist’s semantic processing engine without a team of computer scientists. We created five interactive dialogues centered on pedagogic questions, such as “What should someone do if she receives a positive result for genetic risk of breast cancer?” This method involved an iterative refinement process of repeated testing with different texts, and successively making adjustments to the tutor’s expectations and settings to improve performance. The goal of this method was to enable BRCA Gist to interpret and respond to answers in a manner that best facilitates learning. We developed a method to analyze the efficacy of the tutor’s dialogues. We found that BRCA Gist’s assessment of participants’ answers was highly correlated with the quality of answers found by trained human judges using a reliable rubric. Dialogue quality between users and BRCA Gist, predicted performance on a breast cancer risk knowledge test completed after the tutor. The appropriateness of BRCA Gist feedback also predicted the quality of answers and breast cancer risk knowledge test scores

A natural language intelligent tutoring system for training pathologists: Implementation and evaluation

Introduction We developed and evaluated a Natural Language Interface (NLI) for an Intelligent Tutoring System (ITS) in Diagnostic Pathology. The system teaches residents to examine pathologic slides and write accurate pathology reports while providing immediate feedback on errors they make in their slide review and diagnostic reports. Residents can ask for help at any point in the case, and will receive context-specific feedback. Research questions We evaluated (1) the performance of our natural language system, (2) the effect of the system on learning (3) the effect of feedback timing on learning gains and (4) the effect of ReportTutor on performance to self-assessment correlations. Methods The study uses a crossover 2 × 2 factorial design. We recruited 20 subjects from 4 academic programs. Subjects were randomly assigned to one of the four conditions-two conditions for the immediate interface, and two for the delayed interface. An expert dermatopathologist created a reference standard and 2 board certified AP/CP pathology fellows manually coded the residents' assessment reports. Subjects were given the opportunity to self grade their performance and we used a survey to determine student response to both interfaces. Results Our results show a highly significant improvement in report writing after one tutoring session with 4-fold increase in the learning gains with both interfaces but no effect of feedback timing on performance gains. Residents who used the immediate feedback interface first experienced a feature learning gain that is correlated with the number of cases they viewed. There was no correlation between performance and self-assessment in either condition. © 2007 Springer Science+Business Media B.V

Leaving hints: Using player in-game hints to measure and improve learning

Student reflection has been shown to be important for learning in educational domains. In this study, we embedded a student reflection task into a video game to diagnose how players were constructing new knowledge. The game took place in a space station in which odd things had been happening. In order to secure a position on the space station, players had to improve their decision making and solve the mystery. As part of the game narrative, players reflected on each learning opportunity or mini-game by providing hints for future players at the end of each round. A corpus of 674 hints from 41 players, playing a 60-min version of the game were coded independently by two coders. Coding covered four levels of understanding in the hints and ranged from a simple restatement of information to a deeper reflection that integrated ideas and created new knowledge. Analyzing hints provided an in-game learning measure that may complement other measures and a way to understand game play experience that did not interrupt game flow. This study provides some recommendations for the design of embedding user hints into video games