Introducing a new proforma for the safe use of intraoperative tourniquets in orthopaedic surgery.

INTRODUCTION: The routine use of pneumatic tourniquets in orthopaedic surgery is widely adopted in current practice; however, practice varies considerably based mainly on anecdotal and cultural traditions. This Quality Improvement Project evaluated current service as per the newly published British Orthopaedic Association Standards for Trauma & Orthopaedics guideline on 'The Safe Use of Intraoperative Tourniquets'. METHODS: Patient records were reviewed retrospectively for all patients who underwent orthopaedic surgery in September 2021 at one NHS hospital trust. Simultaneously, a nine-question survey was distributed to the orthopaedic teams allowing assessment of non-quantifiable aspects of the guidelines. The results were delivered as a local presentation, and trust-wide dissemination of posters using the mnemonic 'PRESSURE' was used to educate staff. The quantitative audit was repeated twice, after this intervention (March 2022) and after the advent of a new electronic patient record system with an online proforma (January 2023). RESULTS: There was significant improvement (p<0.05) in all aspects of tourniquet documentation between the audit cycles. Maximum advised tourniquet duration was exceeded in <2% of cases regardless of guideline publication. Recommended pressures were used in less than one-third of cases in all audit cycles, with no significant change throughout. More than 50% of respondents sized their tourniquet on 'whatever looked best fit'. CONCLUSIONS: Despite tourniquet usage being part of the UK Trauma & Orthopaedic Surgery curriculum, this study is the first to highlight a lack of compliance with 'gold standard' guidelines and the need for increased training for staff to ensure patients are exposed to the safest possible environment. Although electronic proformas can aid recording of information, the limitation to change is cultural tradition and anecdotal experience.

J-2156, a small molecule somatostatin type 4 receptor agonist, alleviated hindpaw hypersensitivity in the streptozotocin-induced rat model of painful diabetic neuropathy but with a 2-fold decrease in potency at an advanced stage in the model, mimicking morphine.

There is a large unmet need for novel pain-killers to improve relief of painful diabetic neuropathy (PDN). Herein, we assessed the efficacy of the somatostatin type 4 (SST4) receptor agonist, J-2156, for relief of PDN in rats. Diabetes was induced with streptozotocin (STZ; 70 mg/kg) and bilateral hindpaw hypersensitivity was fully developed by 8-week post-STZ. In the intervals, 8-12-weeks (morphine-sensitive phase; Phase 1) and 16-18-weeks (morphine-hyposensitive phase; Phase 2) post-STZ, rats received a single dose of intraperitoneal (i.p.) J-2156 (10, 20, 30 mg/kg), gabapentin (100 mg/kg i.p.), subcutaneous morphine (1 mg/kg) or vehicle. Hindpaw withdrawal thresholds (PWTs) were assessed using von Frey filaments pre-dose and at regular intervals over 3-h post-dose. In Phase 1, J-2156 at 30 mg/kg evoked significant anti-allodynia in the hindpaws with maximal effect at 1.5 h compared with 1 h for gabapentin and morphine. The durations of action for all three compounds were greater than 3 h. The corresponding mean (±SEM) extent and duration of anti-allodynia (ΔPWT AUC) for gabapentin did not differ significantly from that for J-2156 (30 mg/kg) or morphine. However, in Phase 2, the ΔPWT AUC for morphine was reduced to approximately 25% of that in Phase 1, mirroring our previous work. Similarly, the mean (±SEM) ΔPWT AUC for J-2156 (30 mg/kg) in Phase 2 was approximately 45% of that for Phase 1 whereas for gabapentin the mean (±SEM) ΔPWT AUCs did not differ significantly (p > 0.05) between the two phases. Our findings further describe the preclinical pain relief profile of J-2156 and complement previous work in rat models of inflammatory pain, neuropathic pain and low back pain. SST4 receptor agonists hold promise as novel therapeutics for the relief of PDN, a type of peripheral neuropathic pain that is often intractable to relief with clinically used drug treatment options.

Spontaneous Avascular Necrosis of the Humeral Head Following COVID-19 Vaccination.

We report a case of a 40-year-old man who presented with left shoulder pain and marked functional impairment two days after receiving the second dose of the Pfizer COVID-19 vaccine. Advanced imaging demonstrated focal avascular necrosis (AVN) of his humeral head. Initial management included simple analgesics, activity modification, and an ultrasound-guided intra-articular hydrodilatation injection. The patient subsequently had an improved range of motion but persistent severe shoulder pain. He has now been offered surgical intervention. Despite having risk factors for developing AVN previously, the patient did not demonstrate any recent risk factors for developing the disease. COVID-19 vaccination is known to cause severe joint pain and stiffness rarely. However, avascular necrosis is not a known or documented side effect. His symptoms arose directly after the administration of the vaccine, with no other demonstrable cause. Therefore, we are reporting COVID-19 vaccination as a potential new risk factor for AVN of the humeral head.

Medical Student Perception of Lifestyle Medicine and Willingness to Engage in Lifestyle Counseling: A Pilot Study of Allopathic and Osteopathic Medical Students.

Introduction. This study assessed medical students' perception of lifestyle medicine and readiness to engage in lifestyle counseling. Methods. All medical students in one allopathic and one osteopathic medical school received a survey involving items designed to measure their awareness and interest in lifestyle medicine, perception of physicians serving as lifestyle role models for patients, and intent to practice lifestyle counseling. Results. Two hundred and eight-nine subjects (145 allopathic and 144 osteopathic students) responded to the survey. A total of 24.1% of responding allopathic students had heard about lifestyle medicine compared with 53.9% of responding osteopathic students (P < .01). A total of 90.5% of allopathic students rated their current knowledge of lifestyle medicine as inadequate or poor compared with 78.7% of osteopathic students (P < .01). Ninety-two percent of all respondents wanted to learn more about lifestyle medicine, while 95.2% believed they would provide more effective counseling if they were trained sufficiently to serve as a healthy lifestyle role model for their patients. Conclusions. Both cohorts favored learning more about lifestyle medicine and believed physicians should provide lifestyle counseling to patients with chronic diseases. Given these findings, and the demonstrated benefits of lifestyle medicine-based health care, the authors suggest that training in lifestyle medicine be increased in undergraduate medical education.

WASH, nutrition and health-seeking behavior during COVID-19 lockdowns: Evidence from rural Bangladesh.

A general lockdown to minimize to slow transmission of COVID-19 in Bangladesh came into effect on March 26th and lasted until May 30th. The lockdown had far-reaching economic implications for the population, with many facing economic hardship due to loss of income. Despite the attempt of the government to ease economic hardship by means of social safety net packages, people suffered from poor access to health services, and financial and food insecurity. This is likely to have disastrous consequences for the nutritional status of young children. This cross-sectional study measured the impact of the first general lockdown on food consumption of young children, access to water, handwashing and health seeking behavior, and the ability to maintain livelihood among households with children under the age of 5, in rural Bangladesh. The result of the analysis suggest that loss of income was reported by almost all respondents across all socio-economic groups. However, the poorest households were less likely to provide for sufficient food for their families and had to reduce consumption of food. Diet diversity and food intake-particularly animal protein sources-for young children were severely affected. On the other, increased awareness of handwashing and access to soap were also reported. The pandemic is likely to be detrimental to the nutritional status of children in Bangladesh and can exacerbate existing health inequities. Strong social safety net programs are needed to protect vulnerable populations to consequences of restrictive measures, supported in design and implementation by non-governmental organizations.

Reverse shoulder replacement versus hemiarthroplasty for proximal humeral fracture in elderly patients: a systematic review.

This systematic review of the literature aims to analyse current knowledge to inform choice between hemiarthroplasty (HA) and reverse total shoulder arthroplasty (rTSA) for managing proximal humerus fractures (PHF) in elderly patients; the aim is to understand if rTSA can be considered the gold standard for treating PHF in the elderly when surgical fixation or conservative treatment is not viable options. Studies reporting outcomes and complications of PHF treated with shoulder arthroplasty in the elderly were included. Studies were in English and published after 2008. Evidence levels I, II, III and IV were included. According to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a comprehensive literature search was conducted using Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and PubMed search engines, as well as the Cochrane Central Register of Controlled Trials. General data collected were study design, number of patients treated with HA and rTSA, age of patients (mean, mean and SD, mean and range), length of follow-up, type of implant, and clinical outcomes. rTSA can be regarded as the gold standard for surgical management of displaced 3 and 4-part fractures in the elderly. However, the literature offers mostly low-quality studies, thereby requiring further work to achieve a full understanding of this important topic.

Growing Need for Primary Care Physicians Caring for Cancer Survivors.

BACKGROUND: A rising population of cancer survivors is accompanied by a shortage of oncologists for continuity of care. This study examined the physicians who provided most of the care for cancer survivors, along with written information provided to the survivors before transfer of care. METHODS: Data were collected through the CDC-sponsored Behavioral Risk Factor Surveillance System. Our analysis involved states whose respondents completed a cancer survivorship module from 2016 to 2020. Primary measures were the proportions of physician specialists who provided most of their subsequent health care and the proportions of survivors who received written summaries of their care and instructions. RESULTS: The 36,737 cancer survivor respondents came from 33 states. Most of their health care came from primary care physicians [family physicians (42.3%, 95% CI: 41.3-43.2%) and general internists (26.0%, 95% CI: 25.2-26.9%)]. When seen by primary care physicians rather than subspecialists, a lower proportion of patients recalled receiving summaries of either their cancer treatments (44.3%, 95% CI: 42.5 to 46.2 vs 50.5%, 95% CI: 49.4 to 51.7%) or follow-up instructions (69.9%, 95% CI: 68.8 to 71.0% vs 78.7%, 95%CI 77.1 to 80.2%), regardless of their cancer type. CONCLUSIONS: Regardless of their cancer type, two-thirds of survivors received most of their health care from primary care physicians. Collaborative community-based care within a shared decision-making framework is essential to prioritize and individualize patients' understandings and needs in this growing population.

Application of Decomposition Analysis of Spatial Accessibility (DASA) in Health Services Research.

Withdrawal mapping is effective in showing the educational impact of residency programs and medical schools. It is often used for advocacy and education purposes, but it lacks grounding in the theoretical foundation of spatial accessibility research. This study proposes an improved technique called Decomposition Analysis of Spatial Accessibility, or DASA, to decompose spatial accessibility by applying the withdrawal mapping concept to the classical 2SFCA application. This study applies the DASA technique to three case studies with policy implications. The first case study details the contribution of Black surgeons to public access to the surgical workforce. The second case study details the contribution of international medical graduates from the original seven travel-ban countries. The third case study demonstrates the market competition between family physicians and general pediatricians. The study showcases the usefulness (particularly for workforce-planning for underserved populations) of the DASA technique in understanding subgroup contributions in spatial accessibility analyses.

Diversity of Department Chairs in Family Medicine at US Medical Schools.

BACKGROUND: As designated department leader, chairs need to be sensitive to diversity and inclusiveness for recruitment and retention of faculty and visibility to medical students and resident physicians. The purpose of this analysis is to describe diversity by sex and race/ethnicity of family medicine (FM) chairs as a beginning to understand trends. METHODS: This cross-sectional, observational study involved 2018 to 2020 data from the Association of American Medical Colleges Faculty Roster. We compared this data with other department chairs, faculty, medical school matriculants, and the US general population. RESULTS: There were 407 FM chair observations. While many FM chairs were White males, this was lower than all other clinical departments combined. The proportion of chairs who were under-represented minorities was highest in FM (16.7%) compared with all other departments The distributions of FM chairs who were Black, Asian, and Native American were comparable with the US population. The proportions of Hispanic FM chairs, FM faculty, and medical school matriculants lagged behind the population. CONCLUSION: Diversity of department chairs in FM is greater than many other clinical departments and more representative of the US general population. Attention by chairs to leadership development of females and recruitment of Hispanic faculty are priorities.

An Alternative Athlete Monitoring System Using Cost-Effective Inertial Sensing Instrumentation.

An examination of the human gait is feasible using inertial sensing. The embedded accelerometer and gyroscope in an inertial measurement unit can evaluate physical activity-based sports and this unit is relatively affordable compared to global positioning systems or video recording quantification. This study developed a cost-effective sports monitoring investigation method with an inertial sensor attached to the right leg of the athletes. In total, four parameters were simultaneously tracked to assess the entire sensor performance in real-time. The accelerometer measured the typical leg angle when walking and running, whereas the gyroscope processed the raw data to obtain the stride frequency from the time-domain data. Moreover, a comparison between the accelerometer and gyroscope was presented while simultaneously attaining the signal to convert the time-domain data to frequency results. Also, the number of strides and linear velocity was expressed as results in this study. To confirm the results, a statistical hypothesis test was implemented for all obtained results. The results indicated that the inertial sensing instrumentation used in this study is promising and could be an affordable alternative option for a sports monitoring system.

Trends in Cochlear Implantation in Texas: An Exploration of Outpatient Discharge Data, 2010 to 2017.

OBJECTIVES: To describe trends in cochlear implantation (CI) disparities in Texas using an all-payer database from 2010 to 2017. METHODS: Texas Outpatient Surgical and Radiological Procedure Data, a public use data file, was accessed to analyze outpatient CI cases for Texas. Variables analyzed include patient age, sex, race/ethnicity, and insurance status. Population data from the American Community Survey generated CI utilization rates by patient demographic characteristics. RESULTS: There were 6158 CI cases identified during the study period. The number of CI per year nearly doubled from 497 in 2010 to 961 in 2017. The majority of CI recipients were white (59.5%), male (51.9%), and privately insured (47.9%). All sub-populations statewide had more CI in 2017 compared to 2010, with the overall CI per 100 000 population increasing from 1.98 to 3.50 per 100 000 population. Patients over 75 demonstrated the greatest increase in the CI rate per 100 000 population, increasing from 4.60 in 2010 to 14.30 in 2017. Regarding race/ethnicity, all sub-populations noted an increase in the CI per 100 000 population, with white patients demonstrating the highest rate in 2017, at 4.36 CI per 100 000 population. Asian patients had a 502% increase in the CI rate (from 0.42 to 2.53), compared with 87.9%, 84.4%, and 69.2% increases for white, Black, and Hispanic populations, respectively. CONCLUSIONS: CI became more widespread between 2010 and 2017, benefiting certain populations more than others. Black and Hispanic populations had lower CI per 100 000 population than their white peers, while patients >65 years of age accounted for the greatest increase in CI.

Buccal mucosal graft urethroplasty for anterior urethral stricture, experience from a low-income country.

BACKGROUND/PURPOSE: This study was conducted to present our experience in urethral mucosal graft urethroplasty to repair urethral stricture, as the first experience in our context. METHODS: This is a prospective hospital-based study that had been designed to review management outcomes of buccal mucosal graft urethroplasty for anterior urethral stricture from January 2017 to January 2019. RESULTS: The total number of involved patients was 60. The success rate was found to be 90% (n = 54), while 6 (10%) had a recurrence of stricture. Pain and pain combined bleeding from internal suture lines were the only early complication encountered in 50 (83.3%) and 2 (3.3%) patients, respectively. late complications occurred as follows 14 (23.3%) patients had UTI, 12 (20%) had wound infections, 8 (13.3%) had changes in ejaculation, and decrease in intensity of orgasm, and 6 (10%) had erectile dysfunction. One of the long-term complications was graft diverticulum in one case and was treated conservatively (in ventral on lay BMG). CONCLUSION: Improvement of the service in limited resources countries like Sudan and was reflected in the excellent outcome of BMG urethroplasty as treatment of anterior urethral stricture (success rate 90%).

Subspecialization in Obstetrics and Gynecology: Is It Affecting the Future Availability of Women's Health Specialists?

The growth in the number of obstetrics and gynecology resident graduates pursuing fellowships has exceeded growth in the number of resident graduates, because more fellowship programs are being developed in more subspecialties rather than additional residency programs. Approximately 1 in 4 residents pursues subspecialty training, compared with 1 in 12 in 2001. The number of fellowships remains competitive, because nearly all programs fill their match and the number of applicants exceeds the number of positions. Graduating residents who serve as frontline women's health specialists need to serve as leaders of interprofessional teams to better serve their patients, especially in underserved areas.

Emergency department presentation of opioid use disorder and alcohol use disorder.

Mixing alcohol and opioid prescription medications can have serious health consequences. This study examines demographic and geographic differences in opioid use disorders (OUD) and alcohol use disorders (AUD) in emergency department (ED) presentations in the state of Texas. Using all diagnosis codes, the study examined discharge records for ED visits related to AUD and OUD in Texas for 2017. The study classified visits into three mutually exclusive groups (AUD-only, OUD-only, and AUD/OUD) and reported the number of visits, fatalities, total charges, proportions, and rates per 100,000 population by patient demographic characteristics. Chi square statistics assessed the association between patient characteristics and ED visit type, and the study used analysis of variance to compare ED visit rates by patient demographics. The study also fitted a multinomial logistic regression w to predict ED visit type by patient demographic and geographic characteristics. There were 221,363 OUD and AUD ED visits from Texans in 2017. Among them, 3863 had both AUD and OUD. There were 2443 fatalities related to AUD-only ED visits, whereas this rate was 292 for OUD-only ED visits. The majority of these patients had Medicare and Medicaid. AUD-only ED visits were more prevalent (680.7 vs 112.5 per 100,000 population) and resulted in higher overall charges than OUD-only ED visits ($6.1 billion vs $1 billion in total charges). However, AUD/OUD ED visits resulted in higher total charges on average than either OUD-only or AUD-only ED visits. Compared to patients with outpatient discharge, patients with inpatient admissions were more likely to belong to the OUD-only visit group (OR = 1.20, 95% CI: 1.17-1.23) or the AUD/OUD visit group (OR = 2.44, 95% CI: 2.28-2.61) than to the AUD-only visit group. Compared to urban patients, rural patients were less likely to belong to OUD-related visit groups than the AUD-only visit group. In conclusions, AUD was more prevalent than OUD among ED visits and resulted in a higher number of fatalities and higher medical charges. Current health policy regarding substance use that is heavily tilted toward curbing the opioid crisis remains woefully tolerant to AUDs. While efforts to curb opioid misuse should continue, future efforts should raise awareness among ED providers of the disease burden of and social harms caused by alcoholism and alcohol addiction.

Recent Trends in Faculty Promotion in U.S. Medical Schools: Implications for Recruitment, Retention, and Diversity and Inclusion.

PURPOSE: Faculty promotion is important for retention and has implications for diversity. This study provides an update on recent trends in faculty promotion in U.S. medical schools. METHOD: Using data from the Association of American Medical Colleges Faculty Roster, the authors examined trends in faculty promotion over 10 years. Promotion status for full-time assistant and full-time associate professors who started between 2000 and 2009 inclusive was followed from January 1, 2010 to January 1, 2019. The authors used bivariate analyses to assess associations and promotion rates by sex, race/ethnicity, department, tenure status, and degree type. RESULTS: The promotion rate for assistant professors was 44.3% (2,330/5,263) in basic science departments, 37.1% (17,232/46,473) in clinical science departments, and 33.6% (131/390) in other departments. Among clinical departments, family medicine had the lowest rate of promoting assistant professors (24.4%; 484/1,982) and otolaryngology the highest rate (51.2%; 282/551). Faculty members who were male (38.9%; 11,687/30,017), White (40.0%; 12,635/31,596), tenured (58.7%; 98/167) or tenure-eligible (55.6%; 6,653/11,976), and holding MDs/PhDs (48.7%; 1,968/4,038) had higher promotion rates than, respectively, faculty who were female (36.3%; 7,975/21,998), minorities underrepresented in medicine (URM; 31.0%; 1,716/5,539), nontenured (32.5%; 12,174/37,433), and holding other/unknown degrees (20.6%; 195/948; all P < .001). These differences were less pronounced among associate professors; however, URM and nontenured faculty continued to have lower promotion rates compared with White, Asian, or tenured faculty at the associate professor level. CONCLUSIONS: Promotion rates varied not only by faculty rank but also by faculty sex, race/ethnicity, department, tenure status, and degree type. The differences were more pronounced for assistant professors than associate professors. URM faculty members, particularly assistant professors, were promoted at lower rates than their White and Asian peers. More research to understand the drivers of disparities in faculty promotion seems warranted.