Pub Date : 2019-11-26DOI: 10.1097/CORR.0000000000001070
P. Thornley, M. Bhandari
Osteoporosis is characterized by low bone mineral density changing the architecture of bone, which increases susceptibility to low-energy fractures [9]. Patients with osteoporotic vertebral fractures, the most-common type of osteoporosis fracture, are more likely to have increased spine-related disability, increased risk of future vertebral fracture, heightened fear of falling, and even increased risk of death [2, 5, 6]. Among US women older than 50 years of age, there is an estimated 25% prevalence of vertebral fractures however only 30% of vertebral fractures come to clinical attention, making estimates of the impact of all vertebral fractures difficult to assess [1]. Exercise programs have the potential to decrease the rate of bone resorption and may improve muscle strength and balance, preventing falls [7, 10]. Therapeutic exercise is often recommended for patients sustaining vertebral fractures to reduce pain and morbidity. However, there is controversy about how effective such exercise programs are, and which type of exercise program—if any—is most effective. This Cochrane systematic review with limited meta-analysis [4] is an update of a previous Cochrane review of the same title from 2013 and includes two additional studies (216 more patients) [3, 11]. In the current review, the authors reviewed all randomized and quasi-randomized controlled trials (nine trials, 749 patients) and compared exercise or active physical therapy interventions with placebo or non-exercise control group patients with a history of vertebral fracture [4]. The authors found that low-level evidence showed that exercise likely improves physical
{"title":"Cochrane in CORR®: Exercise for Improving Outcomes after Osteoporotic Vertebral Fracture.","authors":"P. Thornley, M. Bhandari","doi":"10.1097/CORR.0000000000001070","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001070","url":null,"abstract":"Osteoporosis is characterized by low bone mineral density changing the architecture of bone, which increases susceptibility to low-energy fractures [9]. Patients with osteoporotic vertebral fractures, the most-common type of osteoporosis fracture, are more likely to have increased spine-related disability, increased risk of future vertebral fracture, heightened fear of falling, and even increased risk of death [2, 5, 6]. Among US women older than 50 years of age, there is an estimated 25% prevalence of vertebral fractures however only 30% of vertebral fractures come to clinical attention, making estimates of the impact of all vertebral fractures difficult to assess [1]. Exercise programs have the potential to decrease the rate of bone resorption and may improve muscle strength and balance, preventing falls [7, 10]. Therapeutic exercise is often recommended for patients sustaining vertebral fractures to reduce pain and morbidity. However, there is controversy about how effective such exercise programs are, and which type of exercise program—if any—is most effective. This Cochrane systematic review with limited meta-analysis [4] is an update of a previous Cochrane review of the same title from 2013 and includes two additional studies (216 more patients) [3, 11]. In the current review, the authors reviewed all randomized and quasi-randomized controlled trials (nine trials, 749 patients) and compared exercise or active physical therapy interventions with placebo or non-exercise control group patients with a history of vertebral fracture [4]. The authors found that low-level evidence showed that exercise likely improves physical","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"28 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83674014","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-26DOI: 10.1097/CORR.0000000000001073
J. McMenamin, W. Teo, B. S. Bal
Clinical practice guidelines represent prima facie authority (meaning, that which is presumed correct unless proven otherwise) such that diligent adherence to practice guidelines should reduce the risk of malpractice litigation. In practice, however, this is not always the case. While guidelines can sometimes be introduced as a defense by an accused physician, injured patients can just as well use them to allege a breach of the standard of care. Given the limitations and shortcomings associated with clinical practice guidelines— including obsolescence, conflicts of interest, and inconsistencies with the standard of care—we believe that clinical practice guidelines should not be admissible as evidence in medical malpractice litigation.
{"title":"Medicolegal Sidebar: Clinical Practice Guidelines-Do They Reduce Professional Liability Risk?","authors":"J. McMenamin, W. Teo, B. S. Bal","doi":"10.1097/CORR.0000000000001073","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001073","url":null,"abstract":"Clinical practice guidelines represent prima facie authority (meaning, that which is presumed correct unless proven otherwise) such that diligent adherence to practice guidelines should reduce the risk of malpractice litigation. In practice, however, this is not always the case. While guidelines can sometimes be introduced as a defense by an accused physician, injured patients can just as well use them to allege a breach of the standard of care. Given the limitations and shortcomings associated with clinical practice guidelines— including obsolescence, conflicts of interest, and inconsistencies with the standard of care—we believe that clinical practice guidelines should not be admissible as evidence in medical malpractice litigation.","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"2 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82269449","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-26DOI: 10.1097/corr.0000000000001069
S. Leopold
When we talk about driving after orthopaedic surgery, the conversation really has two parts: When do patients return to driving, and when should they? One recent, high-quality survey study [13] suggests that a high proportion of patients returned to driving after major lower-extremity reconstructions within a couple weeks of surgery and another systematic review [3] found that some resumed driving within days. I’m going to try to keep a neutral tone and say this as scientifically as I can: That’s nuts. We know that most patients who were opioid-naı̈ve prior to undergoing THA and TKA are still using narcotic analgesics a month after surgery (and the proportion is higher among those who took opioids before surgery) [4], and that opioid use is associated with an increased risk of fatal motor-vehicle accidents [7] as well as with increased culpability in such crashes [1]. And, of course, being off of narcotics is just one element of driving readiness; medical impairment (as is present in the weeks following surgery) [15], and things like brake-response time and brake pressure—which may not normalize for amonth or longer aftermajor surgery [3]—are some of the many others. While the senior author of that last study expressed in an interview that the patient is responsible to decide when to resume driving [5], others suggest that relying on patients’ judgment is neither scientific nor prudent [14], as human psychology suggests that they are likely to overestimate their abilities and underestimate the risks [6]. This matters to surgeons mainly because we care about the health and well-being of our patients. But I hasten to add that it also matters to us because physicians are considered “mandatory reporters” in some states (that is, we are responsible to report patients to the state if we believe their level of impairment meets the state’s threshold) [11], and because patients have successfully sued their physicians for car accidents that occur after surgery [2]. With this as background, I’m excited to present some of the highest-quality experimental evidence I’ve read on this topic in this month’s Clinical Orthopaedics and Related Research [9]. A team lead by Steven M. Raikin MD, from the Rothman Institute in Philadelphia, PA, USA, found that nearly 10% of patients did not pass a brakereaction time test 6 weeks after undergoing right-sided total ankle arthroplasty, tending to reinforce the concern that patients who drive within a few weeks of major lower-limb surgery really are taking a big risk. Since surgeons are not going to give a driving test, Dr. Raikin’s team also found some easy-toidentify parameters that were associated with failing the test they administered: More pain (and even a little bit counts: those who passed had a median VAS score of 1 out of 10, while those who failed had a median of 3), and greater joint stiffness. A note from the Editor-In-Chief: In “Editor’s Spotlight,” one of our editors provides brief commentary on a paper we bel
当我们谈论骨科手术后的驾驶时，谈话实际上有两个部分:病人什么时候恢复驾驶，什么时候应该恢复驾驶?最近一项高质量的调查研究[13]表明，很大比例的患者在下肢重建术后几周内恢复驾驶，另一项系统综述[3]发现一些患者在几天内恢复驾驶。我将尽量保持中立的语气，尽可能科学地说:这太疯狂了。我们知道，大多数在接受THA和TKA之前是阿片类药物的患者在手术后一个月仍在使用麻醉性镇痛药(在术前服用阿片类药物的患者中这一比例更高)[4]，阿片类药物的使用与致命机动车事故的风险增加有关[7]，并增加了此类事故的罪责[1]。当然，戒掉毒品只是促使人们做好准备的一个因素;医学损伤(如在手术后的几周内出现)[15]，以及像制动反应时间和制动压力这样的东西——在大手术后的一个月或更长时间内可能无法恢复正常[3]——是许多其他因素中的一部分。虽然最后一项研究的资深作者在接受采访时表示，患者有责任决定何时恢复驾驶[5]，但也有人认为，依靠患者的判断既不科学也不谨慎[14]，因为人类心理学表明，他们可能会高估自己的能力，低估风险[6]。这对外科医生来说很重要，主要是因为我们关心病人的健康和幸福。但我要赶紧补充一点，这对我们也很重要，因为在一些州，医生被认为是“强制性报告者”(也就是说，如果我们认为病人的损伤程度达到了州的阈值，我们有责任向州报告病人)[11]，而且因为病人已经成功地就手术后发生的车祸起诉了他们的医生[2]。在此背景下，我很高兴在本月的《临床骨科及相关研究》(Clinical orthopopatics and Related Research)上发表我所读到的关于这一主题的一些最高质量的实验证据[9]。来自美国宾夕法尼亚州费城罗斯曼研究所的Steven M. Raikin医学博士领导的一个研究小组发现，近10%的患者在接受右侧全踝关节置换术6周后没有通过制动时间测试，这加强了人们的担忧，即在重大下肢手术后几周内开车的患者确实冒着很大的风险。由于外科医生不会进行驾驶测试，雷金博士的团队还发现了一些容易识别的参数，这些参数与他们进行的测试失败有关:更痛(即使是一点点也很重要:通过的人的VAS评分中值为1分(满分10分)，而不及格的人的VAS评分中值为3分)，关节僵硬程度更高。总编辑的注释:在“编辑聚焦”中，我们的一位编辑对一篇我们认为特别重要且值得普遍关注的论文提供了简短的评论。在解释了我们的选择之后，我们将呈现“第5条”，在这条视频中，编辑将通过对“编辑聚焦”中这篇文章的作者的一对一采访，深入了解这一发现的背后。我们欢迎读者对我们所有的专栏和文章进行反馈;请将您的意见发送到eic@clinorthop.org。作者证明，他本人及其直系亲属均无任何可能与所提交文章产生利益冲突的商业协会(如咨询公司、股权、股权、专利/许可安排等)。所表达的观点是作者的观点，不反映CORR或骨关节外科医生协会的观点或政策。此评论引用的文章可在:DOI: 10.1097/CORR.0000000000000881。S. S. Leopold MD(;)，临床骨科及相关研究，1600 Spruce St, Philadelphia, PA 19013 USA, Email: sleopold@clinorthop.org
{"title":"Editor's Spotlight/Take 5: When is it Safe to Drive After Total Ankle Arthroplasty?","authors":"S. Leopold","doi":"10.1097/corr.0000000000001069","DOIUrl":"https://doi.org/10.1097/corr.0000000000001069","url":null,"abstract":"When we talk about driving after orthopaedic surgery, the conversation really has two parts: When do patients return to driving, and when should they? One recent, high-quality survey study [13] suggests that a high proportion of patients returned to driving after major lower-extremity reconstructions within a couple weeks of surgery and another systematic review [3] found that some resumed driving within days. I’m going to try to keep a neutral tone and say this as scientifically as I can: That’s nuts. We know that most patients who were opioid-naı̈ve prior to undergoing THA and TKA are still using narcotic analgesics a month after surgery (and the proportion is higher among those who took opioids before surgery) [4], and that opioid use is associated with an increased risk of fatal motor-vehicle accidents [7] as well as with increased culpability in such crashes [1]. And, of course, being off of narcotics is just one element of driving readiness; medical impairment (as is present in the weeks following surgery) [15], and things like brake-response time and brake pressure—which may not normalize for amonth or longer aftermajor surgery [3]—are some of the many others. While the senior author of that last study expressed in an interview that the patient is responsible to decide when to resume driving [5], others suggest that relying on patients’ judgment is neither scientific nor prudent [14], as human psychology suggests that they are likely to overestimate their abilities and underestimate the risks [6]. This matters to surgeons mainly because we care about the health and well-being of our patients. But I hasten to add that it also matters to us because physicians are considered “mandatory reporters” in some states (that is, we are responsible to report patients to the state if we believe their level of impairment meets the state’s threshold) [11], and because patients have successfully sued their physicians for car accidents that occur after surgery [2]. With this as background, I’m excited to present some of the highest-quality experimental evidence I’ve read on this topic in this month’s Clinical Orthopaedics and Related Research [9]. A team lead by Steven M. Raikin MD, from the Rothman Institute in Philadelphia, PA, USA, found that nearly 10% of patients did not pass a brakereaction time test 6 weeks after undergoing right-sided total ankle arthroplasty, tending to reinforce the concern that patients who drive within a few weeks of major lower-limb surgery really are taking a big risk. Since surgeons are not going to give a driving test, Dr. Raikin’s team also found some easy-toidentify parameters that were associated with failing the test they administered: More pain (and even a little bit counts: those who passed had a median VAS score of 1 out of 10, while those who failed had a median of 3), and greater joint stiffness. A note from the Editor-In-Chief: In “Editor’s Spotlight,” one of our editors provides brief commentary on a paper we bel","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"29 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88113892","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-25DOI: 10.1097/CORR.0000000000001059
A. Barg
Ankle fractures are one of the most-common fractures of the lower extremity, with a reported incidence of about 190 per 100,000 persons per year. Up to 25% of all patients with ankle fractures undergo surgery (most commonly, open reduction and internal fixation), which may help to avoid post-operative long-term sequelae including post-traumatic ankle osteoarthritis [8]. Post-operative pain is inevitable, and physicians who manage it must be mindful of the opioid epidemic in the United States. Although less than 5% of the world’s population, Americans consume more than 80% of the world’s prescribed opioids [13]. Beyond the serious nature of opioid abuse and dependence, physicians must also consider that postoperative opioid administration may inhibit bone healing. One animal model showed that post-operative use of opioid pain medication resulted in weaker and slower callus formation compared with controls [6]. One study demonstrated that patients with surgical fracture treatment who take more opioids reported greater pain intensity and less satisfaction with pain relief [4]. Another clinical study of 9995 humeral shaft fractures found that post-operative use of opioids was associated with fracture nonunion [3]. In the last two decades, post-operative opioid monotherapy gained prominence both because of aggressive marketing by pharmaceutical companies, and concerns about side effects of non-steroidal anti-inflammatory drugs (NSAIDs), including evidence associating them with delayed union or nonunion [13]. Multimodal analgesia typically includes several classes of analgesics and antiinflammatory drugs (such as NSAIDs, selective cyclooxygenase-2 inhibitors, acetaminophen, paracetamol, neuromodulatorymedications, opioid agonists, glucocorticoids, N-Methyl D-Aspartate antagonists) as well as local anesthetic techniques (wound infiltration and intraarticular injections), and sometimes peripheral nerve blocks [9]. One study found that multimodal analgesia substantially reduced the length of hospitalization in patients who underwent fusion surgery of the ankle and hindfoot [12]. However, this study has several limitations including retrospective character of the study, small number of patients included into this study, and the heavy selections bias as the selection for receiving the pain protocol was solely left to the surgeon’s discretion [12]. Therefore, the results of this study should be interpreted with great caution [10]. In the current study, McDonald and colleagues [11] found that perioperative ketorolac administration may help to reduce the post-operative opioid consumption. This study is important because it demonstrates a simple protocol how to reduce opioid consumption and to improve pain management in patients who had ankle fracture surgery. Surgical treatment of the ankle is one of the most common surgical procedures in foot and ankle as well as in general traumatology. It is our “daily This CORR Insights is a commentary on the article “How
{"title":"CORR Insights®: How Does Perioperative Ketorolac Affect Opioid Consumption and Pain Management After Ankle Fracture Surgery?","authors":"A. Barg","doi":"10.1097/CORR.0000000000001059","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001059","url":null,"abstract":"Ankle fractures are one of the most-common fractures of the lower extremity, with a reported incidence of about 190 per 100,000 persons per year. Up to 25% of all patients with ankle fractures undergo surgery (most commonly, open reduction and internal fixation), which may help to avoid post-operative long-term sequelae including post-traumatic ankle osteoarthritis [8]. Post-operative pain is inevitable, and physicians who manage it must be mindful of the opioid epidemic in the United States. Although less than 5% of the world’s population, Americans consume more than 80% of the world’s prescribed opioids [13]. Beyond the serious nature of opioid abuse and dependence, physicians must also consider that postoperative opioid administration may inhibit bone healing. One animal model showed that post-operative use of opioid pain medication resulted in weaker and slower callus formation compared with controls [6]. One study demonstrated that patients with surgical fracture treatment who take more opioids reported greater pain intensity and less satisfaction with pain relief [4]. Another clinical study of 9995 humeral shaft fractures found that post-operative use of opioids was associated with fracture nonunion [3]. In the last two decades, post-operative opioid monotherapy gained prominence both because of aggressive marketing by pharmaceutical companies, and concerns about side effects of non-steroidal anti-inflammatory drugs (NSAIDs), including evidence associating them with delayed union or nonunion [13]. Multimodal analgesia typically includes several classes of analgesics and antiinflammatory drugs (such as NSAIDs, selective cyclooxygenase-2 inhibitors, acetaminophen, paracetamol, neuromodulatorymedications, opioid agonists, glucocorticoids, N-Methyl D-Aspartate antagonists) as well as local anesthetic techniques (wound infiltration and intraarticular injections), and sometimes peripheral nerve blocks [9]. One study found that multimodal analgesia substantially reduced the length of hospitalization in patients who underwent fusion surgery of the ankle and hindfoot [12]. However, this study has several limitations including retrospective character of the study, small number of patients included into this study, and the heavy selections bias as the selection for receiving the pain protocol was solely left to the surgeon’s discretion [12]. Therefore, the results of this study should be interpreted with great caution [10]. In the current study, McDonald and colleagues [11] found that perioperative ketorolac administration may help to reduce the post-operative opioid consumption. This study is important because it demonstrates a simple protocol how to reduce opioid consumption and to improve pain management in patients who had ankle fracture surgery. Surgical treatment of the ankle is one of the most common surgical procedures in foot and ankle as well as in general traumatology. It is our “daily This CORR Insights is a commentary on the article “How ","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"22 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89553891","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-25DOI: 10.1097/CORR.0000000000001076
G. Friedlaender, L. Friedlaender
The terms “dwarf” and “dwarfism” (generally applied to individuals with achondroplasia) have a relatively recent appearance in the medical literature [3, 9]. The terms were first used in a clinical manner in the late 19th [13] and early 20th century [12], but did not become established for this purpose until associated with the detailed descriptions of the genetically based condition of achondroplasia in the 1950s [8]. Regardless of when the first medical reference to dwarfism appeared, that date is far more recent than the descriptions depicted with incredible accuracy by Spanish painter Diego Rodrı́guez de Silva y Velázquez (1599-1660), under the patronage of King Philip IV [7]. Born in Seville, in southwest Spain, Velázquez was a descendent of tradesfolk from Portugal who probably were Jewish conversos (products of the Inquisition) [14, 15]. He pursued his passion for art with formal training prior to the age of 12. Before leaving for Madrid in 1622, Velázquez was already established as an outstanding artist in Seville. With the introductions and opportunities afforded by his regional fame and his demonstrated talents (and the recent death of King Philip IV’s previously favorite painter, Rodrigo de Villandrando), he quickly won favor at the royal palace. Approaching the end of his highly acclaimed career, and despite his humble lineage, Velázquez was knighted in 1658 [4, 6]. Velázquez’s portraits, with their outstanding detail and perspective that reflected both technical realism and emotional transparency, remained his primary focus toward the end of his formidable career. One of his most acclaimed portraits, Las Meninas (The Ladies-in-Waiting; [Fig. 1]), includes images of dwarfs, and serves as an incredible example of his observational skills [7] Velázquez has likely contrived the scene depicted in Las Meninas, and done so to make several points [6, 10]. Most obvious is the insertion of the artist himself at the far left, as he is the largest figure in the painting. Depicted with brush, palette, and mahlstick in hand, he is in command of the content of the canvas by virtue of skill and observation. Indeed, Velázquez is making a statement about the control the artist has in the creative process of painting. The scene also provides commentary on the nature of the royal court, but his focus on the young infanta (Princess Margaret Theresa), absent the physical presence of King Philip IV and QueenMariana (although their reflections are seen in the mirror on the back wall), allows an informality and relaxation unavailable, by convention, in formal depictions of adult nobility [5]. The young regent, in the center of the painting is surrounded by attendants, including a chaperone, body guard, the queen’s chamberlain and head of the royal tapestries standing in the doorway, as well as her dog and two dwarfs at the far right of the canvas (Fig. 2). The dwarfs, A note from the Editor-in-Chief: I am pleased to present the next installment of “Art in Sc
术语“侏儒”和“侏儒症”(通常用于软骨发育不全的个体)在医学文献中出现的时间相对较晚[3,9]。这些术语在19世纪末和20世纪初首次用于临床，但直到20世纪50年代对软骨发育不全的遗传基础疾病的详细描述才被确立。不管第一次侏儒症的医学文献是什么时候出现的，这个日期远比西班牙画家迭戈·罗德里格斯·德·席尔瓦(1599-1660)在国王菲利普四世的赞助下以令人难以置信的准确性描绘的描述要近得多。Velázquez出生于西班牙西南部的塞维利亚，是葡萄牙商人的后裔，他们可能是犹太教皈依者(宗教裁判所的产物)[14,15]。他在12岁之前就接受了正式的艺术训练。在1622年离开马德里之前，Velázquez已经在塞维利亚建立了杰出的艺术家地位。由于他在当地的名声和他所展示的才能(以及国王菲利普四世以前最喜欢的画家罗德里戈·德·维兰多最近去世)，他很快赢得了王室的青睐。在他备受赞誉的职业生涯即将结束时，尽管他的出身卑微，Velázquez还是在1658年被封为爵士[4,6]。Velázquez的肖像，以其出色的细节和视角，反映了技术现实主义和情感透明，仍然是他的主要焦点，直到他的可怕的职业生涯结束。他最著名的肖像画之一《宫女》(The Ladies-in-Waiting);[图1])，包括侏儒的图像，并作为他的观察技巧的一个令人难以置信的例子[7]Velázquez很可能设计了《宫女图》中描绘的场景，这样做是为了证明几个观点[6,10]。最明显的是在最左边插入了艺术家本人，因为他是画中最大的人物。他手里拿着画笔、调色板和mahmahstick，凭借技巧和观察力掌控着画布上的内容。的确，Velázquez是在声明艺术家在绘画创作过程中的控制力。这一场景也提供了对皇家宫廷性质的评论，但他把重点放在了年轻的公主(玛格丽特·特蕾莎公主)身上，没有国王菲利普四世和王后玛丽安娜的身影(尽管他们的倒影在后墙的镜子里可以看到)，这给了一种非正式和放松，这是传统上对成年贵族的正式描绘所没有的。年轻的摄政王，在画的中心被随从包围，包括监护人，保镖，女王的侍从和站在门口的皇家织毯的负责人，以及她的狗和两个小矮人在画布的最右边(图2)。小矮人，主编的注释:我很高兴为大家呈现下一篇“科学中的艺术”，由加里·弗里德兰德和琳达·弗里德兰德共同撰写。Gary是耶鲁大学医学院(Yale School of medicine)骨科与康复系的Wayne O. Southwick教授和名誉主席;琳达·弗里德兰德(Linda Friedlaender)是耶鲁大学英国艺术中心教育高级策展人。在一起，他们将从一个迷人的有利位置分享观察:艺术和医学的交集。我们欢迎读者对我们所有的专栏和文章进行反馈;请发送您的意见toeic@clinorthop.org。作者证明其本人及其直系亲属均无任何可能与所提交文章产生利益冲突的商业协会(如咨询公司、股票所有权、股权、专利/许可安排等)。本文仅代表作者个人观点，不代表CORR或骨关节外科医师协会的观点或政策。G. E. Friedlaender MD (MD)，耶鲁大学医学院，邮编208071，康涅狄格州纽黑文，06520-8071，邮箱:gary。friedlaender@yale.edu
{"title":"Art in Science: Velázquez and Dwarfism-The Art of Observation.","authors":"G. Friedlaender, L. Friedlaender","doi":"10.1097/CORR.0000000000001076","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001076","url":null,"abstract":"The terms “dwarf” and “dwarfism” (generally applied to individuals with achondroplasia) have a relatively recent appearance in the medical literature [3, 9]. The terms were first used in a clinical manner in the late 19th [13] and early 20th century [12], but did not become established for this purpose until associated with the detailed descriptions of the genetically based condition of achondroplasia in the 1950s [8]. Regardless of when the first medical reference to dwarfism appeared, that date is far more recent than the descriptions depicted with incredible accuracy by Spanish painter Diego Rodrı́guez de Silva y Velázquez (1599-1660), under the patronage of King Philip IV [7]. Born in Seville, in southwest Spain, Velázquez was a descendent of tradesfolk from Portugal who probably were Jewish conversos (products of the Inquisition) [14, 15]. He pursued his passion for art with formal training prior to the age of 12. Before leaving for Madrid in 1622, Velázquez was already established as an outstanding artist in Seville. With the introductions and opportunities afforded by his regional fame and his demonstrated talents (and the recent death of King Philip IV’s previously favorite painter, Rodrigo de Villandrando), he quickly won favor at the royal palace. Approaching the end of his highly acclaimed career, and despite his humble lineage, Velázquez was knighted in 1658 [4, 6]. Velázquez’s portraits, with their outstanding detail and perspective that reflected both technical realism and emotional transparency, remained his primary focus toward the end of his formidable career. One of his most acclaimed portraits, Las Meninas (The Ladies-in-Waiting; [Fig. 1]), includes images of dwarfs, and serves as an incredible example of his observational skills [7] Velázquez has likely contrived the scene depicted in Las Meninas, and done so to make several points [6, 10]. Most obvious is the insertion of the artist himself at the far left, as he is the largest figure in the painting. Depicted with brush, palette, and mahlstick in hand, he is in command of the content of the canvas by virtue of skill and observation. Indeed, Velázquez is making a statement about the control the artist has in the creative process of painting. The scene also provides commentary on the nature of the royal court, but his focus on the young infanta (Princess Margaret Theresa), absent the physical presence of King Philip IV and QueenMariana (although their reflections are seen in the mirror on the back wall), allows an informality and relaxation unavailable, by convention, in formal depictions of adult nobility [5]. The young regent, in the center of the painting is surrounded by attendants, including a chaperone, body guard, the queen’s chamberlain and head of the royal tapestries standing in the doorway, as well as her dog and two dwarfs at the far right of the canvas (Fig. 2). The dwarfs, A note from the Editor-in-Chief: I am pleased to present the next installment of “Art in Sc","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"289 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77038530","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-25DOI: 10.1097/CORR.0000000000001057
A. Grzegorzewski
Osteonecrosis of the femoral head in children, known as Legg-Calvé-Perthes disease (LCPD), behaves unpredictably [1, 5, 9]. A long list of factors can influence the surgeon’s treatment options, including age of the onset, size of the lesion, femoral head subluxation, presence or absence of greater trochanter hypertrophy, premature growth plate arrest, bilaterality, limitation of hip motion (particularly in abduction). Surgeons can use radiographs to diagnose LCPD, although MRI has proven more useful [2, 12]. There is a debate regarding the choice of treatment for patients in the Herring B, B/C, or C groups, and among patients with Catterall Group III or IV LCPD [5, 9, 16]. Using the Stulberg classification, which has prognostic implications for further function and development of hip degeneration [5, 9, 16], comparable results have been found at the end of growth whether we treat LCPD with non-surgical containment treatment methods or surgically. Hypertrophy of the greater trochanter in the course of LCPD sometimes results in shortening of the resting length and lever arm of the abductors, leading to functional hip weakness and/or restricting the abduction in the hip joint. To assess greater trochanteric hypertrophy, we can use articulotrochanteric distance, articulotrochanteric distance index, and center-trochanteric distance [3, 6, 13]. Two surgical procedures—greater trochanteric apophyseodesis and greater trochanteric descent—have been used to try to prevent this condition, which can impair functional hip biomechanics [4, 8, 15]. The current study by Haskel and colleagues [7] quantifies the change in the hip joint morphology and strength of gluteus muscles under greater trochanteric apophyseodesis or greater trochanteric descent and compared those changes with patients who did not have surgery. Even after surgical treatment, neither greater trochanteric apophyseodesis nor greater trochanteric descent improved the neck-shaft angle, neck length, Stulberg type, or gluteus muscle strength of patients with LCPD compared with those treated non-surgically [7].
{"title":"CORR Insights®: Isolated Trochanteric Descent and Greater Trochanteric Apophyseodesis Are Not Effective in the Treatment of Post-Perthes Deformity.","authors":"A. Grzegorzewski","doi":"10.1097/CORR.0000000000001057","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001057","url":null,"abstract":"Osteonecrosis of the femoral head in children, known as Legg-Calvé-Perthes disease (LCPD), behaves unpredictably [1, 5, 9]. A long list of factors can influence the surgeon’s treatment options, including age of the onset, size of the lesion, femoral head subluxation, presence or absence of greater trochanter hypertrophy, premature growth plate arrest, bilaterality, limitation of hip motion (particularly in abduction). Surgeons can use radiographs to diagnose LCPD, although MRI has proven more useful [2, 12]. There is a debate regarding the choice of treatment for patients in the Herring B, B/C, or C groups, and among patients with Catterall Group III or IV LCPD [5, 9, 16]. Using the Stulberg classification, which has prognostic implications for further function and development of hip degeneration [5, 9, 16], comparable results have been found at the end of growth whether we treat LCPD with non-surgical containment treatment methods or surgically. Hypertrophy of the greater trochanter in the course of LCPD sometimes results in shortening of the resting length and lever arm of the abductors, leading to functional hip weakness and/or restricting the abduction in the hip joint. To assess greater trochanteric hypertrophy, we can use articulotrochanteric distance, articulotrochanteric distance index, and center-trochanteric distance [3, 6, 13]. Two surgical procedures—greater trochanteric apophyseodesis and greater trochanteric descent—have been used to try to prevent this condition, which can impair functional hip biomechanics [4, 8, 15]. The current study by Haskel and colleagues [7] quantifies the change in the hip joint morphology and strength of gluteus muscles under greater trochanteric apophyseodesis or greater trochanteric descent and compared those changes with patients who did not have surgery. Even after surgical treatment, neither greater trochanteric apophyseodesis nor greater trochanteric descent improved the neck-shaft angle, neck length, Stulberg type, or gluteus muscle strength of patients with LCPD compared with those treated non-surgically [7].","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"1883 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89895303","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-21DOI: 10.1097/CORR.0000000000001041
Breana Siljander, Sara S. Van Nortwick, Jessica C Flakne, A. V. Van Heest, Deborah C. Bohn
BACKGROUND Parental leave during graduate medical education is a component of wellness in the workplace. Although every graduate medical education program is required by the Accreditation Council for Graduate Medical Education (ACGME) to have a leave policy, individual programs can create their own policies. The ACGME stipulates that "the sponsoring institution must provide a written policy on resident vacation and other leaves of absence (with or without pay) to include parental and sick leave to all applicants." To our knowledge, a review of parental leave policies of all orthopaedic surgery residency programs has not been performed. QUESTION/PURPOSES: (1) What proportion of orthopaedic surgery residency programs have accessible parental (maternity, paternity, and adoption) leave policies? (2) If a policy exists, what financial support is provided and what allotment of time is allowed? METHODS All ACGME-accredited orthopaedic surgery residency programs in 2017 and 2018 were identified. One hundred sixty-six ACGME-accredited allopathic orthopaedic surgery residency programs were identified and reviewed by two observers. Reviewers determined if a program had written parental leave policy, including maternity, paternity, or adoption leave. Ten percent of programs were contacted to verify reviewer findings. The search was sequentially conducted starting with the orthopaedic surgery residency program's website. If the information was not found, the graduate medical education (GME) website was searched. If the information was not found on either website, the program was contacted directly via email and phone. Parental leave policies were classified as to whether they provided dedicated parental leave pay, provided sick leave pay, or deferred to unpaid Family Medical Leave Act (FMLA) policies. The number of weeks of maternity, paternity, and adoption leave allowed was collected. RESULTS Our results showed that 3% (5 of 166) of orthopaedic surgery residency programs had a clearly stated policy on their program website. Overall, 81% (134 of 166) had policy information on the institution's GME website; 7% (12 of 166) of programs required direct communication with program coordinators to obtain policy information. Further, 9% (15 of 166) of programs were deemed to not have an available written policy as mandated by the ACGME. A total of 21% of programs (35 of 166) offered designated parental leave pay, 29% (48 of 166) compensated through sick leave pay, and 50% (83 of166) deferred to federal law (FMLA) requiring up to 12 weeks of unpaid leave. CONCLUSIONS Although 91% of programs meet the ACGME requirement of written parental leave policies, current parental leave policies in orthopaedic surgery are not easily accessible for prospective residents, and they do not provide clear compensation and length of leave information. Only 3% (5 of 166) of orthopaedic surgery residency programs had a clearly stated leave policy accessible on the program's websit
{"title":"What Proportion of Orthopaedic Surgery Residency Programs Have Accessible Parental Leave Policies, and How Generous are They?","authors":"Breana Siljander, Sara S. Van Nortwick, Jessica C Flakne, A. V. Van Heest, Deborah C. Bohn","doi":"10.1097/CORR.0000000000001041","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001041","url":null,"abstract":"BACKGROUND\u0000Parental leave during graduate medical education is a component of wellness in the workplace. Although every graduate medical education program is required by the Accreditation Council for Graduate Medical Education (ACGME) to have a leave policy, individual programs can create their own policies. The ACGME stipulates that \"the sponsoring institution must provide a written policy on resident vacation and other leaves of absence (with or without pay) to include parental and sick leave to all applicants.\" To our knowledge, a review of parental leave policies of all orthopaedic surgery residency programs has not been performed. QUESTION/PURPOSES: (1) What proportion of orthopaedic surgery residency programs have accessible parental (maternity, paternity, and adoption) leave policies? (2) If a policy exists, what financial support is provided and what allotment of time is allowed?\u0000\u0000\u0000METHODS\u0000All ACGME-accredited orthopaedic surgery residency programs in 2017 and 2018 were identified. One hundred sixty-six ACGME-accredited allopathic orthopaedic surgery residency programs were identified and reviewed by two observers. Reviewers determined if a program had written parental leave policy, including maternity, paternity, or adoption leave. Ten percent of programs were contacted to verify reviewer findings. The search was sequentially conducted starting with the orthopaedic surgery residency program's website. If the information was not found, the graduate medical education (GME) website was searched. If the information was not found on either website, the program was contacted directly via email and phone. Parental leave policies were classified as to whether they provided dedicated parental leave pay, provided sick leave pay, or deferred to unpaid Family Medical Leave Act (FMLA) policies. The number of weeks of maternity, paternity, and adoption leave allowed was collected.\u0000\u0000\u0000RESULTS\u0000Our results showed that 3% (5 of 166) of orthopaedic surgery residency programs had a clearly stated policy on their program website. Overall, 81% (134 of 166) had policy information on the institution's GME website; 7% (12 of 166) of programs required direct communication with program coordinators to obtain policy information. Further, 9% (15 of 166) of programs were deemed to not have an available written policy as mandated by the ACGME. A total of 21% of programs (35 of 166) offered designated parental leave pay, 29% (48 of 166) compensated through sick leave pay, and 50% (83 of166) deferred to federal law (FMLA) requiring up to 12 weeks of unpaid leave.\u0000\u0000\u0000CONCLUSIONS\u0000Although 91% of programs meet the ACGME requirement of written parental leave policies, current parental leave policies in orthopaedic surgery are not easily accessible for prospective residents, and they do not provide clear compensation and length of leave information. Only 3% (5 of 166) of orthopaedic surgery residency programs had a clearly stated leave policy accessible on the program's websit","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"45 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"81644936","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-19DOI: 10.1097/CORR.0000000000001062
B. Nolan
Although the restoration of the normal radial bow has long been known to be a key step in the fixation of forearm fractures [7], similar attention has not been paid to restoring anatomic curvature of the ulna. In fact,we use straight plates forwhat has traditionally been thought of as a straight bone. But as Hreha and colleagues [2] show in the current study, sometimes it is important to bend or contour a plate before applying it to a fractured ulna. It is well established that the articulation between the radius and ulna, including the interosseous membrane, substantially affects pronation and supination of the forearm [1, 3, 5, 6]. But might we further improve functional outcomes following treatment of forearm fractures by meticulously restoring the native anatomyof the ulna in the same fashion as we restore the radial bow? Hreha and colleagues [2] cleverly adapted the methods of earlier studies (one that measured the ulna’s sagittal bow [4] and another that measured the radius in the coronal plane [7]) to define normal ranges of anatomic bowing of the ulna in an adult population. They found that the ulna is anything but straight; it is bowed substantially both in the coronal and sagittal planes. Knowing this can help us in practice because we must understand normal anatomy in order to restore it
{"title":"CORR Insights®: What Is the Normal Ulnar Bow in Adult Patients?","authors":"B. Nolan","doi":"10.1097/CORR.0000000000001062","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001062","url":null,"abstract":"Although the restoration of the normal radial bow has long been known to be a key step in the fixation of forearm fractures [7], similar attention has not been paid to restoring anatomic curvature of the ulna. In fact,we use straight plates forwhat has traditionally been thought of as a straight bone. But as Hreha and colleagues [2] show in the current study, sometimes it is important to bend or contour a plate before applying it to a fractured ulna. It is well established that the articulation between the radius and ulna, including the interosseous membrane, substantially affects pronation and supination of the forearm [1, 3, 5, 6]. But might we further improve functional outcomes following treatment of forearm fractures by meticulously restoring the native anatomyof the ulna in the same fashion as we restore the radial bow? Hreha and colleagues [2] cleverly adapted the methods of earlier studies (one that measured the ulna’s sagittal bow [4] and another that measured the radius in the coronal plane [7]) to define normal ranges of anatomic bowing of the ulna in an adult population. They found that the ulna is anything but straight; it is bowed substantially both in the coronal and sagittal planes. Knowing this can help us in practice because we must understand normal anatomy in order to restore it","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"70 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"90479394","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-19DOI: 10.1097/CORR.0000000000001068
P. Manner, S. Goodman
{"title":"Guest Editorial: The Current Use of Biologics and Cellular Therapies in Orthopaedics: Are We Going Down the Right Path?","authors":"P. Manner, S. Goodman","doi":"10.1097/CORR.0000000000001068","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001068","url":null,"abstract":"","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"29 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88440037","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-19DOI: 10.1097/CORR.0000000000001058
R. El-Hawary
Kyphosis in patients with myelomeningocele can cause skin ulceration, pain, and substantial sitting imbalance. Bracing may stabilize the deformity or delay surgical intervention until skeletal maturity, but it is not always effective. Surgical indications include breakdown of the soft-tissue envelope overlying the gibbus, sagittal imbalance, and progressive deformity. This condition is difficult to treat surgically because complications, such as loss of correction, loss of fixation, revision surgery, and even death after surgery are disconcertingly common [1-3, 5, 6, 8-11]. Wound healing and infection are common reasons for reoperation in this population and are likely a result of operating through the tenuous soft-tissue scar of patients with myelomeningocele. By avoiding incisions through the soft-tissue scar, Hyndman’s Halifax kyphectomy and Torode’s technique may decrease the risk of wound-healing problems [3, 12], but they do not eliminate it. Loss of fixation may be caused by anatomic deficiency of the posterior elements and poor bone quality, though pedicle screw fixation has demonstrated some promise in mitigating these issues [1, 5]. In the current study, Petersen and colleagues [9] evaluated the risk of complications and reoperation as well as the impact of surgery on healthrelated quality of life (HRQoL) in children with myelomeningocele undergoing surgical correction of their lumbar kyphosis. Their technique involves posterior fixation using "Sshaped" rods inserted through the foramina of S1 and pedicle screws in the thoracic spine. The authors found that complications (including infection requiring débridement and wound breakdown requiring plastic surgery with advancement flap for coverage) were common and 68% of the patients underwent reoperation [9]. Their study supports several others that have documented a high risk of complications and reoperations in this patient population [2, 8, 10]. The results in the current study are important because the authors evaluated HRQoL in patients treated with kypectomy [9]. While previous studies have focused on surgical outcomes alone, the current study focuses on outcomes from the patient’s perspective. Because they reported improvement in HRQoL, despite a high complication rate, their findings allow clinicians to more confidently counsel patients about the potential impacts of the surgery [9]. Patients will expect that there may be future unplanned reoperations but that their quality of life should still be improved.
{"title":"CORR Insights®: Does Kyphectomy Improve the Quality of Life of Patients With Myelomeningocele?","authors":"R. El-Hawary","doi":"10.1097/CORR.0000000000001058","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001058","url":null,"abstract":"Kyphosis in patients with myelomeningocele can cause skin ulceration, pain, and substantial sitting imbalance. Bracing may stabilize the deformity or delay surgical intervention until skeletal maturity, but it is not always effective. Surgical indications include breakdown of the soft-tissue envelope overlying the gibbus, sagittal imbalance, and progressive deformity. This condition is difficult to treat surgically because complications, such as loss of correction, loss of fixation, revision surgery, and even death after surgery are disconcertingly common [1-3, 5, 6, 8-11]. Wound healing and infection are common reasons for reoperation in this population and are likely a result of operating through the tenuous soft-tissue scar of patients with myelomeningocele. By avoiding incisions through the soft-tissue scar, Hyndman’s Halifax kyphectomy and Torode’s technique may decrease the risk of wound-healing problems [3, 12], but they do not eliminate it. Loss of fixation may be caused by anatomic deficiency of the posterior elements and poor bone quality, though pedicle screw fixation has demonstrated some promise in mitigating these issues [1, 5]. In the current study, Petersen and colleagues [9] evaluated the risk of complications and reoperation as well as the impact of surgery on healthrelated quality of life (HRQoL) in children with myelomeningocele undergoing surgical correction of their lumbar kyphosis. Their technique involves posterior fixation using \"Sshaped\" rods inserted through the foramina of S1 and pedicle screws in the thoracic spine. The authors found that complications (including infection requiring débridement and wound breakdown requiring plastic surgery with advancement flap for coverage) were common and 68% of the patients underwent reoperation [9]. Their study supports several others that have documented a high risk of complications and reoperations in this patient population [2, 8, 10]. The results in the current study are important because the authors evaluated HRQoL in patients treated with kypectomy [9]. While previous studies have focused on surgical outcomes alone, the current study focuses on outcomes from the patient’s perspective. Because they reported improvement in HRQoL, despite a high complication rate, their findings allow clinicians to more confidently counsel patients about the potential impacts of the surgery [9]. Patients will expect that there may be future unplanned reoperations but that their quality of life should still be improved.","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"7 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84375474","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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