Influence of Bone Cement Augmentation on Complications in Cephalomedullary Nail Fixation of Geriatric Intertrochanteric Hip Fractures.

Introduction: The purpose of this study was to determine if augmentation of the helical blade with polymethylmethacrylate bone cement decreases the rates of varus cut-out and medial perforation in geriatric intertrochanteric hip fracture fixation. Methods: This was a retrospective comparative cohort study at two urban Level I trauma centers. Patients with an intertrochanteric hip fracture (classified as AO 31A1-3) who were treated with the TFN-Advanced Proximal Femoral Nailing System (TFNA) from 2018 to 2021 were eligible for the study. Medical records and post-operative radiographs were reviewed to determine procedure complications and reoperations. Results: Of the 179 patients studied, cement augmentation (CA) was used in 93 patients (52%) and no cement augmentation (NCA) was used in 86 (48%). There were no significant differences between group demographics and fracture reduction grades. Varus cut-out occurred three times in the CA group and five times in the NCA group (p = 0.48). Medial perforation occurred three times, all in the NCA group (p = 0.11). The most frequent complication was symptomatic blade lateralization from fracture collapse, with eight occurrences in the CA group compared with two in the NCA group (p = 0.10). There were 10 reoperations in the CA group and 9 in the NCA group (p = 0.99). The most common reason for reoperation was varus cut-out and the most common revision procedure was hip arthroplasty. Conclusions: Intertrochanteric hip fractures treated with the TFNA fixation system with and without cement augmentation have similar complication profiles and reoperation rates.

Improving Medical Student Mentorship in Orthopaedic Surgery.

Introduction: Owing to limited clinical clerkships and travel restrictions related to COVID-19, recent medical student mentorship in orthopaedic surgery has been impacted negatively. The purpose of this quality improvement (QI) project was to determine if medical student awareness of orthopaedics as a possible career field may be improved through a mentoring program designed and delivered by orthopaedic residents. Methods: A five-resident QI team developed four educational sessions aimed at a medical student audience. Forum topics included: (1) orthopaedics as a career, (2) fracture conference, (3) splinting workshop, and (4) residency application process. Pre- and post-forum surveys were administered to student participants to assess changes in their perceptions regarding orthopaedic surgery. Data derived from the questionnaires were analyzed with nonparametric statistical tests. Results: Of 18 forum participants, 14 were men and 4 were women. A total of 40 survey pairs were collected, averaging 10 per session. In the all-participant encounter analysis, there were statistically significant improvements in all outcome measures including interest in, exposure to, and knowledge of orthopaedics; exposure to our training program; and ability to interact with our residents. Those undecided regarding their specialty demonstrated larger increases in post-forum responses, suggesting that the learning experience was more impactful for that subgroup. Conclusions: This QI initiative was a successful demonstration of orthopaedic resident mentorship of medical students, wherein perceptions of orthopaedics were influenced favorably by the educational experience. For some students with limited access to orthopaedic clerkships or formal one-on-one mentoring, forums like these may be an acceptable alternative.

Second Survey of County Health Departments of Kansas and COVID-19: Time for Change in Model for Pandemic Response.

INTRODUCTION: SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus-2) causing COVID-19 (Coronavirus Disease 2019) continues to be widespread in Kansas. County health departments are trying to contain this pandemic. METHODS: This second survey of Kansas county health department directors occurred from August 7 to September 7, 2020. Since the first survey in April, there have been significant increases in the number of positive cases of COVID-19 and related deaths. Thus, the aim of the study was to re-evaluate county-level containment efforts and assess shortfalls that were identified in the April 2020 survey. RESULTS: In total, 41 out of 105 directors responded to the survey. Generally, respondents said there were increased supplies for testing, increased testing centers, shorter time to get test results, and in some cases, increased funding. However, the number of people involved in contact tracing had not increased substantially, which was one of the recommended changes for improving containment. Moreover, of those persons who were tested, only a few (18%) counties inquired if they wear masks in public. From comments reported, there was a sense of employees being overwhelmed, especially among the smaller county health departments. CONCLUSION: As the cases of and deaths from COVID-19 are increasing in the state, especially in high density areas, the respondents to our survey indicated there was continued need for additional funding with easy access, increased staffing, especially for contact tracing, and significant help for effective messaging to improve adherence to public health directives.

Effectiveness of a Pilot Breastfeeding Educational Intervention Targeting High BMI Pregnant Women.

INTRODUCTION: Overweight and obesity during pregnancy are associated with adverse health outcomes leading to increased maternal and neonatal morbidity and mortality. Women with a high body mass index (BMI) also experience low breastfeeding rates. There is limited evidence of effective educational programs that aim to improve length of breastfeeding among this population. The main objective of this pilot educational intervention was to determine knowledge and skills retention at six weeks after completion of a breastfeeding class. METHODS: A two-hour breastfeeding class was offered during the second and third trimester of pregnancy targeting high BMI women. A longitudinal, survey study design was conducted using two data collection points. No comparator group was employed. RESULTS: Baseline mean age of respondents was 26.6 years (SD = 5.7). Respondents who completed post-intervention surveys were largely white (69.2%) followed by Hispanic (15.4%) and non-Hispanic black (15.4%), some college (57.1%), earned less than $50,000/year (64.3%), had employer-provided insurance (53.8%), and did not receive WIC benefits (78.6%). Most respondents had a pre-pregnancy BMI category of overweight (28.6%) or obese (57.1%). The intervention appeared to have some impact on responses. The following were observed: an increased understanding that baby may be fussy in the evening hours and wants to nurse more often (p < 0.002), how to bring baby to the breast (p = 0.004), knowing what to do if breastfeeding hurts (p = 0.031), and knowing what to do when baby has trouble breastfeeding (p = 0.021). CONCLUSION: Consistent with previous findings, all participants in our study reported increased knowledge to breastfeed. Thus, women's confidence to breastfeed their infant is enhanced through knowledge obtained from breastfeeding education. Additional studies are underway to assess breastfeeding behaviors.

Resident Experience Associated with Lung Biopsy Outcomes: A Cross-Sectional Study of Diagnostic Radiology Residents. Does the Level of Training Matter?

INTRODUCTION: Efficient execution of image-guided percutaneous biopsy is a procedural competency milestone in radiology training. Despite the importance of achieving such mastery, literature on successful execution by residents is limited. The purpose of this study was to evaluate resident performance as measured by nondiagnostic biopsy and major complication percentages, on CT-guided transthoracic core needle biopsies (TTNB) of lung and mediastinal lesions. METHODS: A 12-year retrospective cohort study was conducted using charts from an academic hospital, 2006 - 2018, to evaluate TTNBs. Inclusion criteria were ≥ 18 years of age and ≥ 1 follow-up CT scan and chest x-ray. Bivariable associations by outcome(s) were evaluated. RESULTS: Of 1,191 biopsies conducted, case distribution was 41%, 26%, 18%, and 15% for postgraduate years (PGY) 2 - 5, respectively. Results from biopsies were 139 (11.7%) nondiagnostic, 218 (18.3%) benign, and 834 (70.0%) malignant cases. Resident year by nondiagnostic outcome was not significant; p = 0.430. There were 148 major complications. Complication rate by PGY 2 - 5 was 13.0%, 13.3%, 12.9%, and 9.2%, respectively; differences were not significant, p = 0.488. Of the 139 nondiagnostic cases, 42 were re-biopsied during the study period with 81% re-classified as malignant; no repeat biopsy was observed for the remaining 97 nondiagnostic cases. CONCLUSION: Of 1,191 lung/mediastinal biopsies analyzed, nearly 12% were nondiagnostic and over 12% had major complications; neither associated with resident level of experience. Outcomes were not affected significantly by level of training. Residency programs may benefit from affording opportunities for newer PGY classes to participate in procedures. Nondiagnostic cases may benefit from timely, repeat biopsies.

The Role of Multiparametric MRI and MRI-targeted Biopsy in Detecting Clinically Significant Prostate Cancer in the Community Setting: A Retrospective Study.

Multiparametric MRI and the Prostate Imaging-Reporting and Data System (PI-RADS) have emerged as tools to reveal suspicious prostate lesions and MRI-targeted biopsy has shown potential to avoid repeat prostate biopsies and miss fewer significant cancers. This retrospective study sought to assess the differences in diagnostic yield and sampling efficiency between MRI-targeted and standard biopsies in a community urology practice. We concluded that MRI-targeted biopsy was more efficient than a standard biopsy, although neither technique achieved a superior diagnostic yield of clinically significant cancer in our community setting. We recommend that a standard biopsy be performed alongside targeted biopsy.

The Effect of Different Combinations of Three Stacked Half-Hitches and Suture Materials on an Arthroscopic Knot in a Dry or Wet Environment.

Purpose: Evidence is lacking on the effect of different combinations of three stacked half-hitches and suture materials on the loop/ knot security of an arthroscopic knot under cyclic loading conditions. The specific aim of this study was to identify variables, such as stacked half-hitch configurations, suture materials, and testing environments, that affect knot strength and loop security under cyclic loading conditions. Methods: Two suture materials (Orthocord and ForceFiber) were used to tie five differently stacked reversing half-hitches on alternating posts (RHAP) in an arthroscopic knot condition. All knots were evaluated in both dry and wet cyclic loading tests. Results: Knots tied with three identical half-hitches stacked on the same post (Conf #1) resulted in 100% knot slippage regardless of suture material in dry environment. In the wet environment this knot configuration performed slightly better (ForceFiber: 20% survived; Orthocord: 40% survived). With knots tied with one of the half-hitches in the RHAPs reversed, a significant improvement occurred in knot holding compared to Conf #1 (p<0.05). Knots tied with the last half-hitches in the RHAPs reversed using ForceFiber were 100% secure in both test environments; whereas those tied with Orthocord had 70% and 80% security rates in the respective environments. Knots tied with two half-hitches of the RHAPs reversed demonstrated the best overall performance. Conclusion: Significant effects for both stacked half-hitch configurations and suture materials on the knot loop and knot security were observed. Caution should be used when tying the 3 RHAPs in a knot using standard arthroscopic techniques. This study may provide a solution that might improve the maximum failure loads observed between orthopaedic surgeons, and achieve better clinical outcomes. Clinical Relevance: The findings of this study indicate the importance of three reversing half-hitches on alternating posts in performing arthroscopic knot tying, and provide evidence regarding discrepancies of maximum clinical failure loads observed between orthopaedic surgeons leading to better surgical outcomes.

A quantitative evaluation of medication histories and reconciliation by discipline.

BACKGROUND/OBJECTIVE: Medication reconciliation at transitions of care decreases medication errors, hospitalizations, and adverse drug events. We compared inpatient medication histories and reconciliation across disciplines and evaluated the nature of discrepancies. METHODS: We conducted a prospective cohort study of patients admitted from the emergency department at our 760-bed hospital. Eligible patients had their medication histories conducted and reconciled in order by the admitting nurse (RN), certified pharmacy technician (CPhT), and pharmacist (RPh). Discharge medication reconciliation was not altered. Admission and discharge discrepancies were categorized by discipline, error type, and drug class and were assigned a criticality index score. A discrepancy rating system systematically measured discrepancies. RESULTS: Of 175 consented patients, 153 were evaluated. Total admission and discharge discrepancies were 1,461 and 369, respectively. The average number of medications per participant at admission was 8.59 (1,314) with 9.41 (1,374) at discharge. Most discrepancies were committed by RNs: 53.2% (777) at admission and 56.1% (207) at discharge. The majority were omitted or incorrect. RNs had significantly higher admission discrepancy rates per medication (0.59) compared with CPhTs (0.36) and RPhs (0.16) (P < .001). RPhs corrected significantly more discrepancies per participant than RNs (6.39 vs 0.48; P < .001); average criticality index reduction was 79.0%. Estimated prevented adverse drug events (pADEs) cost savings were $589,744. CONCLUSIONS: RPhs committed the fewest discrepancies compared with RNs and CPhTs, resulting in more accurate medication histories and reconciliation. RPh involvement also prevented the greatest number of medication errors, contributing to considerable pADE-related cost savings.

Prevalence of communication disorders in HIV-infected adults.

Few adult patients with HIV/AIDS are evaluated for communication disorders. A broad inventory of the communication disorders was obtained in a convenience sample of 82 adult HIV/AIDS patients who presented for medical appointments. Each participant underwent a head and neck exam and a communications skills evaluation. Speech, language, and cognition were assessed using a 10-item test battery. A 14-item hearing test battery was conducted in a separate session. The primary outcomes were the presence and degree of communication disorders. Head and neck exams revealed 40% with ear-related issues. Only 2 participants showed normal findings on all 24 communication skills assessments. Four demonstrated normal findings on all speech-language-cognitive assessments, whereas 8 had normal findings on the complete hearing test battery. A relatively high prevalence of cognitive and language deficits and central auditory disturbances were found. Clinicians must recognize the potential for communication deficits even in a relatively healthy patient with HIV.

Acute hospital admissions of hospice patients.

BACKGROUND AND METHODS: Research into acute hospital admissions (AHAs) of hospice patients is relatively underdeveloped. The goal of this study, based on the electronic health records (EHR) of a large Midwestern hospice service over a 3-year period, was to identify characteristics of new hospice patients that are associated with an increased risk of later AHAs. RESULTS: Our study of a large and undifferentiated hospice population revealed several important new findings regarding AHA. We found these previously unreported factors associated with elevated AHA rates: 1) hospice diagnoses of terminal heart and lung disease compared with other diagnoses; and 2) the home care setting compared with the nursing home setting. Moreover, previous studies had not looked in detail at the timing of AHA over the course of hospice care or related the timing of AHA to the reason for AHA. CONCLUSIONS: The future agenda for research on AHA of hospice patients should include studies of large and undifferentiated hospice populations like our own, but designed to capture data on socioeconomic status (SES), religion, race/ethnicity, the details of supportive care in place, and a look at specific factors surrounding individual AHAs.

Treatment provider is most predictive of ED dismissal in minimally-injured trauma patients: a retrospective review.

BACKGROUND: Secondary triage protocols have been described in the literature as physiologic (first-tier) criteria and mechanism-related (second-tier) criteria to determine the level of trauma activation. There is debate as to the efficiency of triage decisions based on mechanism of injury which may result in overtriage and overuse of limited trauma resources. Our institution developed and implemented an advanced three-tier trauma alert system in which stable patients presenting with blunt traumatic mechanism of injury would be evaluated by the emergency department (ED) physician rather than the trauma surgeon. The American College of Surgeons Committee on Trauma (ACSCOT) requires that operational changes be monitored and evaluated for patient safety and performance. The primary aim of this study was to evaluate the process, as well as outcomes, of patient care pre and post implementation of the new triage protocol. The secondary aim was to determine predictor variables that were associated with ED dismissal. METHODS: A retrospective blinded pre/post process change implementation explicit chart review was conducted to compare process and outcomes of minimally injured trauma patients who were field triaged by mechanism of injury. Generalized linear modeling was performed to determine which predictor variables were associated with ED dismissal. RESULTS: There were no significant differences in minutes to physician evaluation, CT scan, OR/ICU disposition, readmission rates, safety or quality. Significant differences only occurred in time to chest x-ray, length of stay in ED, and ED dismissal rates. Trauma surgeon and ED physician patient groups did not differ on ISS, age, or sex. The only significant predictor for ED dismissal was treatment provider, with ED physicians 3.6 times more likely to dismiss the patient from the emergency department. CONCLUSIONS: ED physicians provided compble care as measured by safety, timeliness, and quality in minimally-injured patients triaged to our trauma center based only on mechanism of injury. Moreover, ED physicians were more likely to dismiss patients from the ED. A three-tiered internal triaging protocol can redirect resource usage to reduce the burden on the trauma service. This may be increasingly beneficial in trauma models in which the trauma surgeons also serve as critical care intensivists.

Fall risk associated with inpatient medications.

PURPOSE: The association between fall risk and inpatient medications was evaluated. METHODS: A retrospective, case-control study was performed to compare the medication use of patients sustaining at least one fall during hospitalization (case group) with a control group of patients who did not fall. Data were collected from medical records and generated reports. A fall was defined by the hospital as an event in which the patient comes to rest on the floor from a lying, standing, or sitting position. Adult patients (≥18 years of age) admitted between January 1 and December 31, 2006, experiencing a fall at least 48 hours after hospital admission were included in the case group. Each case was matched with one control by age (within five years), sex, admission date (within 30 days), patient care unit, and length of stay. Medications administered within 48 hours before the fall for the case group or designated fall date and time for the control group were documented. RESULTS: Of the 414 documented fall events, 209 patients met the inclusion criteria. Of those patients, 96 matched control patients on all criteria. Significantly more case patients received a greater number of central nervous system (CNS) agents compared with matched control patients (p = 0.017). There was no statistically significant difference in the number of medications from all other drug classes or the total number of medications received by the groups. CONCLUSION: In a sample of hospitalized patients, CNS agents were significantly associated with falls.

Are students less likely to report pertinent negatives in post-encounter notes?

BACKGROUND AND OBJECTIVES: In completing post-encounter notes (PENs), students are believed to under-report about 30% of the important information obtained in the medical history. The resulting incomplete clinical notes can contribute to adverse patient care and medicolegal outcomes. We hypothesized that pertinent negative items would be more likely to be under-reported than positive items. We compared reporting rates for pertinent positive and negative items on two cases in a clinical skills assessment (CSA) taken by all 55 third-year students. Based on standardized patient (SP) checklists, students obtained 87% of both positive and negative items. Scoring of PENs found significant differences in the reporting rates for positive (75%) and negative (52%) items. These results were consistent for each case. Students appear to be able to elicit pertinent negative information from patients but, although these items may be crucial in the medical history, they are significantly more likely than positive items to be omitted from the clinical note.

Do students falsify information in clinical notes?

BACKGROUND: If students report information in a post-encounter note that was allegedly not obtained from the patient, they may be suspected of serious professional misconduct, ie, deliberate falsification of patient data. Over-reporting during a clinical assessment may result in accusations of cheating and even lead to failure of a high-stakes examination. Despite these serious implications, the prevalence and reasons for over-reporting are not clear. We investigated every detected incident of false reporting during our high-stakes clinical skills assessment (CSA) at the end of the third year. Of 73 alleged incidents, 69 were attributed to errors in standardized patient (SP) performance, note scoring, data management, or the design of cases or scoring instruments. The four instances of over-reporting by students were more compatible with mistakes and lack of specificity than deliberate falsification. We conclude that all potential sources of error must be excluded before over-reporting incidents are attributed to deliberate falsification of data by students.