Telemedicine Useful in Common Conditions // Canadians Reversing Osteoporosis? // and More!

Telemedicine Can Work for Common Conditions

What if you could see an orthopedic surgeon without the expense of travel, time off from work, etc.? It could happen, say researchers from Canada. A new study has found that for more common orthopedic conditions, those living in rural areas can benefit from consults via telephone and email. Using encrypted emails and phone calls, orthopedic surgeons at a McGill University Health Centre in Montreal reached out to primary care physicians in six towns in the northern area of Quebec. Most patients involved in the study were being treated for bone fractures.

The study, led by Adam Cota, M.D., found that out of 921 email consults, 731 patients were able to receive treatment from their local doctor with the guidance of an orthopedic surgeon at McGill. On the cost front, the research team estimated a savings of nearly $3.7 million ($5.5 million in Canadian dollars) in medical transportation during the study.

Asked about the challenges of this type of care, Dr. Cota, now an orthopedic trauma fellow at OrthoIndy at St. Vincent Indianapolis, told OTW, “Relying on email based communication for patient management presents some unique difficulties for the consulting surgeon. The inability of the orthopedic surgeon to directly perform a physical exam on a patient can impede establishing a diagnosis. Since our email-based telemedicine program relies on the skill of primary care physicians in the remote communities to procure an accurate patient history and physical examination, a consulting orthopedic surgeon relies on this information to make management and transfer decisions. If there is any ambiguity with regards to a diagnosis or management decision then we have a low threshold to transfer patients to our university health center.”

“There are a couple of precautions when using an email-based telehealth program. Relying on email as the primary means of communication can become a problem for more time sensitive referrals that may require transportation or urgent treatment. We found that 49.5% of our consults required the use of email and a telephone call. The need for adjunct communication by telephone likely reflects the inherent time delay in exchanging emails, which becomes a problem when urgent management decisions need to be made at the remote site. In addition, it is crucial that the management of patient personal information complies with the Health Insurance Portability and Accountability Act (HIPAA). Moreover, patient consent needs to be properly obtained when obtaining and transmitting clinical images. Finally, the consulting physician needs to maintain a low threshold for transporting patients for a face-to-face evaluation if there is any diagnostic uncertainty or an inability to obtain the necessary management at the remote site.”

Canadian Researchers Reversing Osteoporosis?

Researchers from Canada are shedding light on how an injection of stem cells might turn back the clock when it comes to osteoporosis. This work on age-related osteoporosis, conducted by the University of Toronto and The Ottawa Hospital, was just published in STEM CELLS Translational Medicine. The research was led by William Stanford, Ph.D., professor in the department of Cellular and Molecular Medicine at The Ottawa Hospital.

Dr. Stanford commented to OTW, “This work began by asking some very basic bone stem cell biology questions about 15 years ago. In that process, my lab developed a faithful mouse model of age-related (or type II) osteoporosis which we published in the Proceedings of the National Academy of Sciences (USA) in 2013. In that work, we demonstrated that defective maintenance of bone stem cells found among so called mesenchymal stem/stromal cells (MSCs) led to osteoporosis type II, which affects men and women equally and is responsible for most hip fractures. Thus, similar to the method whereby defective maintenance of hematopoietic stem cells leads to bone marrow failure and anemia, we showed that the loss of skeletal stem cells can lead to osteoporosis. At the time, several review articles hailed our work as the first demonstration of an in vivo function of MSCs. We reasoned that if defective MSCs are responsible for age-related osteoporosis, transplantation of healthy MSCs should be able to prevent or treat osteoporosis. This is what we tested in our recently published manuscript.”

“I think my colleague and co-senior author, John Davies, said it best: ‘The huge surprise was to find that the exquisite inner coral-like architecture of the bone structure of the injected animals—which is severely compromised in osteoporosis—was restored to normal.’”

“I would also add that I was shocked by the remarkable amount of bone remodeling that was still taking place six months after this single injection of MSCs, suggesting that the treatment may be sustainable.”

Cadaver Tissue in ACL Surgery Increases Revision Risk

New research led by Gregory B. Maletis, M.D. of Kaiser Permanente has examined 14, 105 cases of anterior cruciate ligament reconstruction (ACLR) and found that using cadaver tissue in ACL reconstructions may increase the risks for revision.

Dr. Maletis told OTW, “For patients with instability due to an anterior cruciate ligament deficiency, reconstruction has been shown to improve knee stability and allow patients to return to a more active lifestyle. Despite the overall success of the operation many patients have a re-injury and tear the graft necessitating a revision. Some factors that may contribute to the increased likelihood of needing a revision surgery are not modifiable such as the patient’s age or gender, but the graft used for the initial reconstruction is at the discretion of the patient and surgeon and therefore it is important to understand how graft choice might impact the likelihood of needing a revision anterior cruciate ligament reconstruction.”

The research team found that after a three-year follow-up, the overall revision rates were 2.5% for bone-patellar tendon-bone autografts, 3.5% for hamstring autografts, and 3.7% for soft tissue allografts.

“We found that the choice of graft at the initial ACLR has an influence on the subsequent risk of revision. Hamstring autografts, irradiated soft tissue allografts, and chemically processed soft tissue allografts were all associated with a higher risk of revision than BPTB [bone–patellar tendon–bone] autografts. We also found that graft processing and time influence the performance of soft tissue allografts, with more highly processed grafts leading to a higher risk of revision at earlier time frames.”