Enhancing frontline workforce volunteerism through exploration of motivations and impact during the COVID-19 pandemic.

OBJECTIVES: During a pandemic, healthcare workers are requested to volunteer for potentially high-risk frontline duties outside of usual hospital and primary care clinic settings in order to better serve vulnerable communities. Examination of volunteer motivations and impact of such experiences can drive more effective pandemic response efforts with regards to volunteer recruitment and retention. This study aims to explore the motivational factors underlying healthcare worker volunteerism in COVID-19 pandemic response operations in the community, and to describe the impact of such operations on volunteers, in order to highlight important volunteer recruitment strategies and ensure volunteer sustainability. METHODS: A qualitative phenomenological approach is taken in this study through the use of semi-structured individual interviews of healthcare staff, to provide in-depth exploration of personal experiences. Staff were purposefully sampled to ensure diversity of personal and professional backgrounds. RESULTS: A total of 35 staff, consisting of 17 males and 18 females from medical, nursing, allied health, and administrative backgrounds, who participated in COVID-19 community-based operations in migrant worker dormitories and swab isolation facilities were interviewed. The main motivational factors were volunteer functions of values, understanding and enhancement. Participants were positively impacted on personal and professional levels, including self-growth, societal awareness, as well as skills development in leadership and team management. CONCLUSIONS: Healthcare organizations should consider volunteer functions in matching individual motivations to volunteer opportunities. Additionally, personal narratives and role-modelling by senior staff can serve as useful adjunct strategies to volunteer recruitment, while providing pre-pandemic preparedness, reassurance of safety, support, and recognition.

From "business continuity" to "back to business" for orthopaedic surgeons during the COVID-19 pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented challenges to healthcare systems worldwide. Orthopaedic departments have adopted business continuity models and guidelines for essential and non-essential surgeries to preserve hospital resources as well as protect patients and staff. These guidelines broadly encompass reduction of ambulatory care with a move towards telemedicine, redeployment of orthopaedic surgeons/residents to the frontline battle against COVID-19, continuation of education and research through web-based means, and cancellation of non-essential elective procedures. However, if containment of COVID-19 community spread is achieved, resumption of elective orthopaedic procedures and transition plans to return to normalcy must be considered for orthopaedic departments. The COVID-19 pandemic also presents a moral dilemma to the orthopaedic surgeon considering elective procedures. What is the best treatment for our patients and how does the fear of COVID-19 influence the risk-benefit discussion during a pandemic? Surgeons must deliberate the fine balance between elective surgery for a patient's wellbeing versus risks to the operating team and utilization of precious hospital resources. Attrition of healthcare workers or Orthopaedic surgeons from restarting elective procedures prematurely or in an unsafe manner may render us ill-equipped to handle the second wave of infections. This highlights the need to develop effective screening protocols or preoperative COVID-19 testing before elective procedures in high-risk, elderly individuals with comorbidities. Alternatively, high-risk individuals should be postponed until the risk of nosocomial COVID-19 infection is minimal. In addition, given the higher mortality and perioperative morbidity of patients with COVID-19 undergoing surgery, the decision to operate must be carefully deliberated. As we ramp-up elective services and get "back to business" as orthopaedic surgeons, we have to be constantly mindful to proceed in a cautious and calibrated fashion, delivering the best care, while maintaining utmost vigilance to prevent the resurgence of COVID-19 during this critical transition period. Cite this article: Bone Joint Open 2020;1-6:222-228.

Ensuring Business Continuity of Musculoskeletal Care During the COVID-19 Pandemic: Experience of a Tertiary Orthopaedic Surgery Department in Singapore.

On February 8, 2020, Singapore raised its Disease Outbreak Response System Condition (DORSCON) level to Orange, indicating that coronavirus 2019 (COVID-19) was a severe disease with high human transmissibility. Using lessons learned from the severe acute respiratory syndrome (SARS) outbreak in 2003, the orthopaedic surgery department at Singapore General Hospital, a tertiary-level referral center, was prepared to handle this pandemic through business-continuity planning. The business that we are referring to is the "business" of orthopaedic surgery, encompassing clinical care, education, research, and administration. There is a lack of literature detailing business-continuity plans of surgical departments during pandemics, with new guidelines being developed. A large proportion of orthopaedic work, such as cases of fracture and infection, cannot be postponed. Even elective surgeries cannot be postponed indefinitely as it could result in detriment to the quality of life of patients. The aim of this article is to detail the business-continuity plans at our institution that allowed the delivery of essential musculoskeletal care through personnel segregation measures during the COVID-19 pandemic. Strategies to ensure the provision of timely medical intelligence, the reduction of nonessential ambulatory visits and surgical procedures, ensuring the safety and morale of staff, and continuing education and research efforts were paramount. As the COVID-19 pandemic unfolds, our posture needs to constantly evolve to meet new challenges that may come our way. Our existing business-continuity plan is not perfect and may not be applicable to smaller hospitals. There is conflict between envisioned normalcy, remaining economically viable as an orthopaedic department, and fulfilling training requirements, and educating the next generation of orthopaedic surgeons on the one hand and the need for segregation, workload reduction, virtual education, and social distancing on the other. Orthopaedic surgeons need to strike a balance between business continuity and adopting sustainable precautions against COVID-19. We hope that our experience will aid other orthopaedic surgery departments in adapting to this new norm, protecting their staff and patients, managing staff morale, and allowing the continuation of musculoskeletal care during the COVID-19 pandemic.

Bisphosphonate-related femoral periosteal stress reactions: scoring system based on radiographic and MRI findings.

OBJECTIVE: The purpose of this study was to review the radiographic and MRI findings of bisphosphonate-related femoral periosteal stress reactions to propose a scoring system for predicting symptoms and fracture risk. MATERIALS AND METHODS: A retrospective study included patients undergoing long-term bisphosphonate therapy who had radiographic evidence of focal femoral periosteal thickening on radiographs and MR images. There were 43 femoral periosteal stress reactions in 33 patients; eight patients underwent MRI. Radiographs and MR images were evaluated for focal cortical thickening (periosteal and endosteal), bone edema, focal cortical abnormalities (radiolucency, striations, cavities), and dreaded black line. The radiographic score (derived with statistical methods) and simple scores (simple radiographic, MRI, and combined scores) were compared with symptoms and fracture outcome. RESULTS: Logistic regression analysis showed an association between radiographic dreaded black line and symptoms (odds ratio, 68.0). Kaplan-Meier and Cox regression analyses showed radiographic dreaded black line (p < 0.0005; hazard ratio, 27.3) and focal cortical radiolucency (p = 0.011; hazard ratio, 6.8) were independent predictors of fracture. The survival score derived from Cox regression coefficients showed good separation of high- and low-risk groups. Mann-Whitney tests showed an association between MRI and combined scores and symptoms (p = 0.036, p = 0.036). The area under the receiver operating characteristic curve suggested better association with symptoms for MRI and combined scores than for simple radiographic scores (1.00, 1.00, 0.93). CONCLUSION: In bisphosphonate-related femoral periosteal stress reactions, radiographic dreaded black line and MRI and combined scores were associated with symptoms, and radiographic survival score was predictive of fracture risk. The relation between MRI and combined scores and fracture was not statistically significant.

Femoral cortical stress lesions in long-term bisphosphonate therapy: a herald of impending fracture?

OBJECTIVE: Lateral cortical stress reactions have been documented to precede femoral insufficiency fractures after long-term bisphosphonate therapy. We studied the natural history of femoral stress lesions associated with long-term bisphosphonate therapy. DESIGN AND SETTING: A retrospective clinical and radiologic review of all patients with radiologically documented femoral stress lesions associated with bisphosphonate therapy was carried out in a tertiary center involved with geriatric trauma care. PATIENTS: Of 1463 geriatric hip fractures occurring from May 1, 2004, to July 31, 2008, 33 were of a distinct metaphyseal-diaphyseal configuration. Thirty-two were on prior bisphosphonate therapy. Sixteen femurs showed a lateral cortical thickening either on prefracture radiographs (four femurs) or on radiographs of the contralateral femur (12 femurs). MAIN OUTCOME MEASURES: Features that predispose to complete stress fractures were determined. The intact femurs were followed up for symptomatic and radiologic progression and occurrence of new lesions. RESULTS: All four cases that fractured had a "dreaded black line" in the lesion, whereas only 1 of 12 patients had this fracture in femurs which remained intact (100% versus 8.3%, P = 0.003). All patients who fractured reported thigh discomfort over 1 month (range, 0.1-9.0 months; standard deviation, 4.0 months), whereas three of 12 patients who did not fracture reported thigh discomfort (100% versus 25%, P = 0.019). In the remaining patients, eight patients were asymptomatic, two patients had reduced symptoms, and one patient had persistent thigh pain at 23.0 months (range, 5-35 months; standard deviation, 10.2 months). One patient was too demented for symptomatic assessment. No patient developed a new lesion. Radiologic stabilization of the lateral cortical thickening was evident on follow-up radiographs. CONCLUSION: Cortical stress reactions associated with prolonged antiresorptive therapy, in the presence of pain and the "dreaded black line," have an increased risk for complete stress fractures.

Meta-analysis comparing total hip arthroplasty with hemiarthroplasty in the treatment of displaced neck of femur fracture.

Displaced neck of femur fracture is a common clinical problem among the elderly population. Our aim is to review previously published randomized controlled trials to establish if total hip arthroplasty (THA) or hemiarthroplasty will offer a superior clinical outcome in this group of patients. We conducted literature search for relevant randomized controlled trials. A total of 407 patients from 3 trials were included in this meta-analysis. In the long-term follow-up, we found that THA patients were able to ambulate better, reported less pain compared with their hemiarthroplasty counterparts, and were less likely to undergo a repeated hip surgery. Considering the more favorable long-term outcomes in THA patients, we conclude that there may be a case to offer THA as the primary treatment of these patients.

An emerging pattern of subtrochanteric stress fractures: a long-term complication of alendronate therapy?

BACKGROUND: Subtrochanteric insufficiency fractures in post-menopausal patients have not been commonly reported in the literature. A recent increase in the incidence of such fractures occurring in patients while on alendronate therapy led us to conduct a retrospective review of these patients in our institution. METHODS: Seventeen patients, with a mean age of 66 years, sustained low energy subtrochanteric fractures within a 20-month period. These patients were incidentally found to be on alendronate therapy for an average of 4.8 years. Clinical data and history were reviewed and roentgenograms were evaluated by a single investigator. All additional imaging and bone mineral density measurements available were analysed. RESULTS: A characteristic fracture configuration suggestive of an insufficiency stress fracture was identified on plain radiographs. This consisted of (a) cortical thickening in the lateral side of the subtrochanteric region, (b) a transverse fracture, and (c) a medial cortical spike. In addition, 9 (53%) patients had bilateral findings of stress reactions or fractures, and 13 (76%) had symptoms of prodromal pain. CONCLUSIONS: These insufficiency fractures could possibly have developed from the over suppression of bone turnover from prolonged alendronate therapy, in keeping with recently published evidence. This study further highlights the need for heightened awareness of alendronate's potential adverse effects.

Acute vascular rejection of xenografts: roles of natural and elicited xenoreactive antibodies in activation of vascular endothelial cells and induction of procoagulant activity.

BACKGROUND: Hyperacute rejection of vascularized discordant xenografts can now be effectively managed. However, acute vascular rejection (AVR) then ensues, resulting in graft destruction, coagulopathy, or both within weeks. The aim of this study was to determine associations between humoral responses to the xenograft and the induction of AVR, coagulopathy, or both. METHODS: In vitro, heat-inactivated, naive or sensitized baboon sera containing xenoreactive natural or elicited antibodies were used to activate porcine aortic endothelial cells (PAEC) in vitro. Tissue factor expression on PAEC was determined as an index of heightened procoagulant activity. In vivo, porcine renal xenografts were transplanted into immunosuppressed baboons, and at the time of rejection or the development of a consumptive coagulopathy, biopsy specimens were obtained for studies of xenoreactive antibody binding and tissue factor expression. RESULTS: In vitro, incubation of PAEC with naive baboon sera containing natural anti-Galalpha1,3Gal (Gal) antibodies resulted in minimal tissue factor induction; the addition of complement boosted procoagulant responses. Elicited xenoreactive antibodies, and to non-Gal epitopes alone, induced high amounts of procoagulant activity on PAEC; the addition of complement resulted in overt cytotoxicity. In vivo, AVR was associated with xenoreactive antibody deposition in the graft. When vascular endothelial binding of xenoreactive antibody was combined with the expression of tissue factor, consumptive coagulopathy developed irrespective of histopathologic features of AVR. CONCLUSIONS: Our in vitro results indicate that elicited antibodies, potentially to non-Gal epitopes, induce endothelial cell activation and tissue factor expression; in vivo, a consumptive coagulopathy occurred when there was xenoreactive antibody deposition and increase of tissue factor.