bluuebunny/crossref_metadata_2025 huggingface dataset:
Transforming Surgical Education through a Resident Robotic Curriculum
Authors: Green Courtney A. , Chern Hueylan , Rogers Stanley J. , Reilly Linda M. , O’Sullivan Patricia
Published: July 2021

Objective:

Here, we describe a systematic approach to design, implement, and assess a robotic surgery curriculum for surgical residents. By describing our process, including identifying and addressing institutional challenges, we illustrate successful development of a robust curriculum.

Summary Background Data:

As robotic-assisted surgeries increase, educational challenges have emerged and illustrate an alarming impact on medical training. Robotic curricula are frequently grounded in the industry’s educational materials resulting in a variety of existing resident curricula that lack cognitive components and critical evaluation. As such, surgical educators struggle to identify the curricular restructuring needs that likely accompany emerging technologies. It is essential to develop a curricular framework for the surgical education community to approach the ongoing and inevitable integration of new technologies.

Methods:

Our process parallels the widely accepted approach to curricular development in medical education described by Kern et al. Using this 6-step model, we describe derivation of a curriculum that was data driven, features multimodal educational strategies, and provides documentation methods that allow for continued evaluation and assessment at the individual and departmental level.

Results:

This study highlights the systematic process of design, implementation and assessment of a robotic surgery curriculum for surgical residents. Built on a robust national and local needs assessment, and further strengthened by preemptive identification of institutional challenges, this curricular model includes a structured documentation system that allows for ongoing evaluation, assessment, and monitoring of curricular progress.

Conclusions:

We illustrate a robustly built curricular structure that can be adopted, adapted, and successfully implemented at other training institutions around the world.
Repair of Humeral Shaft Nonunion With Plate and Screw Fixation and Iliac Crest Bone Graft
Authors: Stevens Nicole M. , Schultz Blake J. , Lowe Dylan T. , Egol Kenneth A.
Published: July 2021

A 58-year-old woman with a proximal 1/3 humeral shaft nonunion presented 2 years after initial injury. We present a technique for nonunion repair, including nonunion site preparation, direct compression of the fracture site using plate osteosynthesis, and iliac crest bone graft harvest and utilization. The purpose of this video is to review humeral shaft nonunion literature and describe our management technique.
Sternoclavicular Joint Reconstruction for Medial Clavicle Fracture Nonunion
Authors: Stevens Nicole M. , Pflug Emily , Lowe Dylan T. , Leucht Philipp
Published: July 2021

Operative management of sternoclavicular fracture-dislocations is recommended in the setting of symptomatic nonunion. Treatment options include open reduction internal fixation, fragment excision, and ligamentous reconstruction. We present a 29-year-old man with a medial clavicle fracture nonunion that previously failed open reduction internal fixation and was treated with sternoclavicular joint reconstruction using tendon allograft.
Elbow Arthrodesis Surgical Technique
Authors: Couso Megan , Sherman Nathan , Lowe Jason
Published: July 2021

Elbow arthrodesis is an uncommon salvage procedure indicated for failed total elbow arthroplasty, segmental bone loss near the elbow, and severe postinfectious or posttraumatic arthritis. This video demonstrates the surgical technique for elbow arthrodesis in a patient with segmental bony defect of the ulna and postinfectious and posttraumatic elbow arthritis after a severe left arm degloving injury with Monteggia fracture dislocation and radial head fracture.
Open Reduction and Internal Fixation of Patella Fracture With Contoured Dorsal Plating
Authors: Brusalis Christopher M. , Gruskay Jordan A. , Bornes Troy D. , Langhans Mark T. , Ricci William M.
Published: July 2021

In this article, we present a novel patella fixation technique using a low-profile highly contoured dorsal mini-fragment locking plate. This procedure is ideally indicated in patients with fracture patterns that are transverse without significant comminution. Long-term clinical studies are being performed to evaluate the effectiveness of this surgical technique.
Circumferential Pelvic Antishock Sheeting
Authors: Maier Lindsay M. , Desgrange Ryan , Ayoola Ayooluwa , Bober Kamil , George Albert , Hoegler Joseph J.
Published: July 2021

Pelvic ring fractures range from low-energy falls in the elderly to high-energy mechanisms in young patients. These injuries can be a significant cause of morbidity and mortality and are frequently associated with additional injuries. Hemorrhage and resultant hemodynamic instability are often associated with high-energy injuries and require prompt management. Circumferential pelvic antishock sheeting is an effective and readily available tool for reducing pelvic volume at the accident scene or in the emergency department, while still allowing access to the abdomen and lower extremities for ongoing resuscitation. This article, and the associated instructional video, reviews the indications and proper technique for placing a pelvic sheet.
Single-Stage Treatment of Fracture-related Infections
Authors: Rice Olivia M. , Phelps Kevin D. , Seymour Rachel , Askam Brad M. , Kempton Laurence B. , Chen Andrew , Dart Scott , Hsu Joseph R.
Published: July 2021

Fracture-related infections (FRIs) remain a significant problem. Many approach FRI cases in a staged fashion, focusing on infection eradication initially and fracture union during subsequent procedures. The literature quotes high success rates with this strategy. However, associated patient morbidity and economic impact are noteworthy. A single-stage FRI treatment, using an antibiotic-coated locked intramedullary nail, also exists. This video details low-cost, antibiotic-coated locked intramedullary nail fabrication in the operating room alongside preliminary results using this technique for acute FRI and septic nonunion treatment.
Acute Repair of Anterior Cruciate Ligament, Posterior Cruciate Ligament, Medial Collateral Ligament, and Posterior Lateral Corner After Knee Dislocation
Authors: Gajari Vamshi , Pritchett Charles , Obremskey William T.
Published: July 2021

This video depicts the materials and steps for the repair of a Schenck classification knee dislocation IV multiligamentous injury and peroneal nerve palsy. The patient had bilateral injuries after a car pinned him to a garage in his cabinet. The video demonstrates primary repair of the avulsions of the right knee with acute repair of anterior cruciate ligament, posterior cruciate ligament, medial collateral ligament, and posterior lateral corner in the patient.
Application of Negative Pressure Wound Therapy
Authors: Tatman Lauren M. , Gajari Vamshi , Obremskey William T.
Published: July 2021

The video depicts the materials and steps for applying negative pressure wound therapy. The clinical case involves a patient who had sustained a thigh Morel-Lavallee lesion that developed overlying skin necrosis and drainage that was treated with surgical debridement and the application of negative pressure wound therapy.
Prolonged, High-Fidelity Simulation for Study of Patient Care in Resource-Limited Medical Contexts and for Technology Comparative Effectiveness Testing
Authors: Pamplin Jeremy C. , Veazey Sena R. , De Howitt Joanne , Cohen Katy , Barczak Stacie , Espinoza Mark , Luellen Dave , Ross Kevin , Serio-Melvin Maria , McCarthy Mary , Colombo Christopher J.
Published: July 2021

OBJECTIVES:

Most high-fidelity medical simulation is of limited duration, used for education and training, and rarely intended to study medical technology. U.S. caregivers working in prehospital, resource-limited settings may need to manage patients for extended periods (hours to days). This “prolonged casualty care” occurs during military, wilderness, humanitarian, disaster, and space medicine. We sought to develop a standardized simulation model that accurately reflects prolonged casualty care in order to study caregiver decision-making and performance, training requirements, and technology use in prolonged casualty care.

DESIGN:

Model development.

SETTING:

High-fidelity simulation laboratory.

SUBJECTS:

None.

INTERVENTIONS:

We interviewed subject matter experts to identify relevant prolonged casualty care medical challenges and selected two casualty types to further develop our model: a large thermal burn model and a severe hypoxia model. We met with a multidisciplinary group of experts in prolonged casualty care, nursing, and critical care to describe how these problems could evolve over time and how to contextualize the problems with a background story and clinical environment with expected resource availability. Following initial scenario drafting, we tested the models with expert clinicians. After multiple tests, we selected the hypoxia model for refinement and testing with inexperienced providers. We tested and refined this model until two research teams could proctor the scenario consistently despite subject performance variability.

MEASUREMENTS AND MAIN RESULTS:

We developed a 6–8-hour simulation model that represented a 14-hour scenario. This model of pneumonia evolved from presentation to severe hypoxia necessitating advanced interventions including airway, breathing, and shock management. The model included: context description, caregiver orientation scripts, hourly progressive physiology tracks corresponding to caregiver interventions, intervention/procedure-specific physiology tracks, intervention checklists, equipment lists, prestudy checklists, photographs of setups, procedure, telementor, and role player scripts, business rules, and data collection methods.

CONCLUSIONS:

This is the first standardized, high-fidelity simulation model of prolonged casualty care described in the literature. It may be used to assess caregiver performance and patient outcomes resulting from that performance during a complex, 14-hour prolonged casualty care scenario. Because it is standardized, the model may be used to compare differences in the impact of new technologies upon caregiver performance and simulated patient outcomes..
Automating Time-Consuming and Error-Prone Manual Nursing Management Documentation Processes
Authors: Haas Oliver , Hutzler Michaela , Egginger Thomas H. , Maier Andreas , Rothgang Eva
Published: July 2021

A German regulation requires nursing managers to document patient-nurse ratios. They have to combine heterogeneous hospital data from different sources. Missing documentation or ratios that are too high lead to sanctions. Automated approaches are needed to accelerate the time-consuming and error-prone documentation process. A documentation and visualization system was implemented. The system allows nursing managers to quickly and automatically create the documentation required by the regulation. Interactive visualization dashboards assist with the analysis of patient and staff numbers. The developed method was effectively used in nursing management tasks. No changes to the information technology infrastructure were needed. The new process is around 35 hours per month faster and less error-prone. The documentation functionality automatically reads the required information and correctly calculates the documentation. The visualization functionality allows nursing managers to assess the current patient-nurse ratios before the documentation is submitted. The method scales to multiple wards and locations. It calculates the sanctions to expect and is easily updatable. The proposed method is expected to decrease nursing administration workloads and facilitate the analysis of nursing management data in a cost-effective way.
Circ_UBR4 Knockdown Alleviates Oxidized Low-Density Lipoprotein-Provoked Growth and Migration of Human Vascular Smooth Muscle Cells by Acting on the miR-637/FOXO4 Pathway
Authors: Ding Ying , Tang Tianfeng , Lu Jun , Wang Jingyu
Published: July 2021

Excessive proliferation and migration of human vascular smooth muscle cells (HVSMCs) induced by oxidized low-density lipoprotein (ox-LDL) are important pathological features of atherosclerosis. Emerging evidence indicates that circular RNAs deregulation is involved in this pathological process. The objective of this study was to explore the role of circular RNA ubiquitin protein ligase E3 component n-recognin 4 (circ_UBR4) in ox-LDL-treated HVSMCs. The expression of circ_UBR4, microRNA-637 (miR-637), and forkhead box O4 (FOXO4) mRNA was detected by quantitative real-time PCR. Cell cycle progression was examined by flow cytometry assay. Cell viability was examined by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay. Cell migration was examined by transwell assay. The protein levels of proliferating cell nuclear antigen, matrix metalloproteinase 2, and FOXO4 were measured by western blot. The relationship between miR-637 and circ_UBR4 or FOXO4 was confirmed by dual-luciferase reporter assay. The results presented that the expression of circ_UBR4 was increased in atherosclerosis serum samples and ox-LDL-treated HVSMCs. Cell cycle progression, cell proliferation, and cell migration were promoted by ox-LDL, whereas circ_UBR4 knockdown inhibited HVSMCs proliferation and migration. MiR-637 was a target of circ_UBR4, and FOXO4 was a target of miR-637. Circ_UBR4 positively regulated FOXO4 expression by targeting miR-637. Circ_UBR4 knockdown-inhibited HVSMCs proliferation and migration were recovered by miR-637 inhibition, and miR-637 restoration-inhibited HVSMCs proliferation and migration were recovered by FOXO4 overexpression. In conclusion, circ_UBR4 knockdown inhibited ox-LDL-induced excessive proliferation and migration of HVSMCs by regulating FOXO4 via targeting miR-637.
The Safe Practice of Female Genital Plastic Surgery
Authors: Furnas Heather J. , Canales Francisco L. , Pedreira Rachel A. , Comer Carly , Lin Samuel J. , Banwell Paul E.
Published: July 2021

The purpose of this article is to guide surgeons in the safe practice of female genital plastic surgery when the number of such cases is steadily increasing. A careful review of salient things to look for in the patient’s motivation, medical history, and physical examination can help the surgeon wisely choose best candidates. The anatomy is described, with particular attention given to the variations not generally described in textbooks or articles. Descriptions are included for labiaplasty, including clitoral hood reduction, majoraplasty, monsplasty, and perineoplasty with vaginoplasty. Reduction of anesthetic risks, deep venous thromboses, and pulmonary emboli are discussed, with special consideration for avoidance of nerve injury and compartment syndrome. Postoperative care of a variety of vulvovaginal procedures is discussed. Videos showing anatomic variations and surgical techniques of common female genital procedures with recommendations to reduce the complication rate are included in the article.
Healthcare is a Team Sport: Stress, Resilience, and Correlates of Well-Being Among Health System Employees in a Crisis
Authors: Meese Katherine A. , Colón-López Alejandra , Singh Jasvinder A. , Burkholder Greer A. , Rogers David A.
Published: July 2021

EXECUTIVE SUMMARY

While the COVID-19 pandemic has added stressors to the lives of healthcare workers, it is unclear which factors represent the most useful targets for interventions to mitigate employee distress across the entire healthcare team. A survey was distributed to employees of a large healthcare system in the Southeastern United States, and 1,130 respondents participated. The survey measured overall distress using the 9-item Well-Being Index (WBI), work-related factors, moral distress, resilience, and organizational-level factors. Respondents were also asked to identify major work, clinical, and nonwork stressors. Multivariate regression was used to evaluate associations between employee characteristics and WBI distress score. Overall, 82% of employees reported high distress (WBI ≥ 2), with nurses, clinical support staff, and advanced practice providers reporting the highest average scores. Factors associated with higher distress included increased job demands or responsibilities, heavy workload or long hours, higher frequency of moral distress, and loneliness or social isolation. Factors associated with lower distress were perceived organizational support, work control, perceived fairness of salary cuts, and resilience. Most factors significantly associated with distress—heavy workloads and long hours, increased job demands, and moral distress, in particular—were work-related, indicating that efforts can be made to mitigate them. Resilience explained a small portion of the variance in distress relative to other work-related factors. Ensuring appropriate staffing levels may represent the single largest opportunity to significantly move the needle on distress. However, the financial impact of the COVID-19 pandemic on the healthcare system may represent a barrier to addressing these stressors.
The Impact of Nursing on Trauma Patient Satisfaction: An Analysis of HCAHPS From 112,283 Patients
Authors: Watts Dorraine D. , Slivinski Andrea , Garland Jeneva M. , Kerley David R. , Wilson Nina Y. , Cooper Tabatha , Howard Kyle , Dunne James , Lieser Mark J. , Berg Gina M. , Wyse Ransom J. , Carrick Matthew M. , Fakhry Samir M.
Published: July 2021

Background:

Assessment of patient satisfaction is central to understanding and improving system performance with the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) national standard survey. However, no large, multi-institutional study exists, which examines the role of nurses in trauma patient satisfaction.

Objective:

To assess the impact of nurses on trauma patient satisfaction.

Methods:

This retrospective, descriptive study of Level I–IV trauma centers in a multistate hospital system evaluated patients 18 years and older admitted with at least an overnight stay. Data were obtained electronically for patients discharged in 2018–2019 who returned an HCAHPS survey. Surveys were linked by an honest broker to demographic and injury data from the trauma registry, and then anonymized prior to analysis. Patients were categorized as “trauma” per the National Trauma Data Standard (NTDS) definition or as “medical” or “surgical” per the HCAHPS definition.

Results:

Of 112,283 surveys from 89 trauma centers, “trauma” patients (n = 5,126) comprised 4.6%, “surgical” 39.0% (n = 43,763), and “medical” 56.5% (n = 63,394). Nurses had an overwhelming impact on “trauma” patient satisfaction, accounting for 63.9% (p < .001) of the variation (adjusted R
2) in the overall score awarded the institution—larger than for “surgery” (59.6%; p < .001) or “medical” (58.4%; p < .001) patients. The most important individual domain contributor to the overall rating of a facility was “nursing communication.”

Conclusions:

The magnitude of the effect of trauma nurses was noteworthy, with their communication ability being the single biggest driver of institutional ratings. These data provide insight for future performance benchmark development and emphasize the critical impact of trauma nurses on the trauma patient experience.
Effect of 0.12% Chlorhexidine Use for Oral Care on Ventilator-Associated Respiratory Infections: A Randomized Controlled Trial
Authors: Kes Duygu , Aydin Yildirim Tugba , Kuru Cuneyt , Pazarlıoglu Fatma , Ciftci Taner , Ozdemir Mehmet
Published: July 2021

Background:

Evidence suggests that the effect of 0.12% chlorhexidine (CHX) use for oral care on the development of ventilator-associated pneumonia (VAP) and ventilator-associated tracheobronchitis (VAT) is lacking. Evidence-based approaches to the prevention of VAP and VAT are of paramount importance for improving patients' outcomes.

Objectives:

This study aimed to (1) compare the effect of 0.12% CHX use for oral care on preventing VAP and VAT with the placebo group, as well as (2) compare its effect on oral health and prevention of oral microbial colonization with the placebo group.

Methods:

Prospective, single-blinded, randomized controlled trial performed in 2 intensive care units at a hospital. The sample comprised 57 mechanically ventilated adults randomly allocated to the 0.12% CHX group and the placebo group. Barnason's oral assessment guide was used to evaluate the oral health of both groups before oral care during the first 24 hr of tracheal intubation (Day 0) and at Day 2 and Day 3. Oropharyngeal secretion, endotracheal tube aspirate, and nonbronchoscopic bronchoalveolar lavage samples were collected on Day 0 and Day 3.

Results:

The rate of VAT development was not statistically different between the groups (p = .318). However, a significant difference existed in the rate of VAP development (p = .043). The frequency of oropharyngeal colonization significantly decreased in the 0.12% CHX group compared with the placebo group at Day 3 (p = .001).

Conclusion:

The use of 0.12% CHX for oral care could be effective for VAP prevention and reducing microbial colonization in mechanically ventilated patients.
Trauma Bay Time Clocks: Influence on Emergency Department Length of Stay
Authors: Hardway Jessica , Samanta Damayanti , Rennie Kelly V. , Evans Kelly Jo , Lasky Tiffany
Published: July 2021

Background:

To monitor the time elapsed since patient arrival in the emergency department, Trauma Services at the study institution installed a large digital stopwatch timer placed at the head of each trauma bay on June 5, 2017. This quality improvement endeavor became an essential component of performance evaluation.

Objective:

The purpose of the study is to measure the impact of trauma bay time clocks on emergency department length of stay.

Methods:

This is a retrospective before-and-after study of trauma activation patients between June 2015 and May 2019. Two 24-month intervals were compared before and after installation of time clocks.

Results:

In full activation patients, outcomes of emergency department length of stay ≤50 min (39.2% vs. 61.7%, p < .001) and time to transfer to intensive care unit ≤56 min (45.3% vs. 55.1%, p = .002) were significantly favorable in the postimplementation phase. Time to first computed tomography scan and time to first operating room from arrival to the emergency department were comparable between both phases. For limited activation patients, positive changes were noted in emergency department length of stay ≤87 min (41.4% vs. 60.6%, p < .001), time to first computed tomography scan ≤32 min (47.7% vs. 53.0%, p = .015), and time to transfer to intensive care unit ≤74 min (50.2% vs. 57.2%, p = .008). Time to first operating room remained comparable between two periods.

Conclusions:

The study institution improved their provision of immediate care by using time clocks in trauma bays. This is a simple and cost-effective intervention and may benefit similar institutions.
Patient-Centered Approaches to Transitional Care Research and Implementation
Authors: Parry Carly , Johnston-Fleece Michelle , Johnson Maurice C. , Shifreen Aaron , Clauser Steven B.
Published: July 2021

Background:

This Special Issue, Future Directions in Transitional Care Research, focuses on the approaches used and lessons learned by researchers conducting care transitions studies funded by the Patient-Centered Outcomes Research Institute (PCORI). PCORI’s approach to transitional care research augments prior research by encouraging researchers to focus on head-to-head comparisons of interventions, the use of patient-centered outcomes, and the engagement of stakeholders throughout the research process.

Objectives:

This paper introduces the themes and topics addressed by the articles that follow, which are focused on opportunities and challenges involved in conducting patient-centered clinical comparative effectiveness research in transitional care. It provides an overview of the state of the care transitions field, a description of PCORI’s programmatic objectives, highlights of the patient and stakeholder engagement activities that have taken place during the course of these studies, and a brief overview of PCORI’s Transitional Care Evidence to Action Network, a learning community designed to foster collaboration between investigators and their research teams and enhance the collective impact of this body of work.

Conclusions:

The papers in this Special Issue articulate challenges, lessons learned, and new directions for measurement, stakeholder engagement, implementation, and methodological and design approaches that reflect the complexity of transitional care comparative effectiveness research and seek to move the field toward a more holistic understanding of transitional care that integrates social needs and lifespan development into our approaches to improving care transitions.
Methods, Ethics, and Cross-Language Considerations in Research With Ethnic Minority Children
Authors: Chatham Rebecca E. , Mixer Sandra J.
Published: July 2021

Background

Qualitative research seeking the perspectives of minority children on child health issues such as childhood obesity and healthy weight care is limited, especially in nursing research.

Objective

Our objective is to share methodological, ethical, and cross-language knowledge gained from conducting an ethnonursing research study. This study focused on providing a voice for ethnic minority children in childhood obesity literature.

Methods

The purpose of the study was to discover cultural influences on healthy weight care in children of Burmese refugees of Karen ethnicity. Researchers may exclude children of ethnic minorities from studies because of the distinct challenges in conducting cross-language research and research with children. We critically examine these challenges. The challenge of being a stranger was addressed by a period of immersion in the children’s activities prior to data collection, in addition to volunteering as an English teacher with Karen adults. The immersion period was crucial for developing the trust needed in child-inclusive research and research in ethnic minority communities. The challenge of designing an inclusive study with families who experience language barriers was addressed with an interpreter who not only spoke Karen but was also a part of the Karen community. The interpreter provided the authentic sociocultural language equivalence needed for the study’s rigor. Ensuring the child’s voice was clearly heard was addressed with member checking. Methodological changes necessitated by a pandemic were a distinct challenge discussed in detail.

Results

We described methods useful for nurse researchers seeking transformative knowledge to reduce health disparities in childhood obesity. Nurse researchers may use these methods related to cross-language research and child research for designing research inclusive of minorities with language barriers.

Discussion

The perspectives of children from ethnic minorities are needed to inform culturally congruent healthy weight care for their communities. The goal in providing transparency of the difficulties, successes, and recommendations for methods in research with children of Burmese refugees is to encourage more nurse researchers to work with marginalized groups. Nurse researchers can inform evidence-based, culturally appropriate interventions to address health inequities of minority communities by including the voice of children from these communities.
A Goat Cadaver as a Cost-effective Resource for Teaching Emergency Medicine Procedures in Kijabe, Kenya
Authors: Theroux Lindly , Steere Mardi , Katz Eric , Jewell Rebekah , Gardner Alison
Published: July 2021

Background

A pediatric emergency medicine and critical care fellowship was recently developed in Kenya through the University of Nairobi/Kenyatta National Hospital and AIC Kijabe Hospital. As part of this training, a week-long trauma and emergency medicine course was developed with emphasis on trauma and emergency medicine procedures. Given limited resources, we developed a course with simulation of procedures centered around utilization of a goat cadaver.

Objective

The aim of the study was to describe fellow and faculty experiences and perspectives when using a goat cadaver to teach emergency medicine procedures by simulation in Kijabe, Kenya.

Methods

A 5-day course was given to 2 fellows with a variety of didactics and simulations after which fellows completed a questionnaire to rate their satisfaction with the content and teaching effectiveness.

Results

The course was rated very highly, with an average content satisfaction score of 4.5 5 and average teaching effectiveness score of 4.4 of 5. Qualitative faculty feedback was positive, with specific learnings allowing ongoing adaptation of this model.

Conclusions

A goat cadaver is a cost-effective resource not often considered that can be adequately used to teach several emergency medicine skills by simulation.
Evaluation of COVID-19–Associated Myocarditis Via Point-of-Care Ultrasound in a Pediatric Patient
Authors: Poteh Ndah Akwesi , Singh Amar Chetram , Starr Seal Rebecca , Khalil Paul Adeeb
Published: July 2021

Coronavirus disease 2019 (COVID-19)–associated myocarditis has been reported from the onset of the pandemic. The presumed etiology is direct damage to the myocardium from severe acute respiratory syndrome coronavirus 2. Common findings include electrocardiogram abnormalities, elevated cardiac markers, and diminished cardiac function. This can lead to heart failure and cardiogenic shock with resultant poor perfusion. Thus, myocarditis has been recognized as a cause of death in patients with COVID-19. Unfortunately, it is difficult to predict the prevalence of myocarditis in these patients given the relative novelty of the pandemic and the lack of available data. Point-of-care ultrasound (POCUS) has been shown to be a useful modality to investigate lung pathology in patients with COVID-19. Bedside cardiac POCUS can also be used to investigate cardiac pathology. This case describes a pediatric patient with COVID-19 who had evidence of myocarditis on POCUS in the pediatric emergency department.
Are Biases Related to Attrition, Missing Data, and the Use of Intention to Treat Related to the Magnitude of Treatment Effects in Physical Therapy Trials?
Authors: Armijo-Olivo Susan , R. da Costa Bruno , Ha Christine , Saltaji Humam , Cummings Greta G. , Fuentes Jorge
Published: July 2021

The objective of this study was to determine the association between biases related to attrition, missing data, and the use of intention to treat and changes in effect size estimates in physical therapy randomized trials. A meta-epidemiological study was conducted. A random sample of randomized controlled trials included in meta-analyses in the physical therapy discipline were identified. Data extraction including assessments of the use of intention to treat principle, attrition-related bias, and missing data was conducted independently by two reviewers. To determine the association between these methodological issues and effect sizes, a two-level analysis was conducted using a meta-meta-analytic approach. Three hundred ninety-three trials included in 43 meta-analyses, analyzing 44,622 patients contributed to this study. Trials that did not use the intention-to-treat principle (effect size = −0.13, 95% confidence interval = −0.26 to 0.01) or that were assessed as having inappropriate control of incomplete outcome data tended to underestimate the treatment effect when compared with trials with adequate use of intention to treat and control of incomplete outcome data (effect size = −0.18, 95% confidence interval = −0.29 to −0.08).

Researchers and clinicians should pay attention to these methodological issues because they could provide inaccurate effect estimates. Authors and editors should make sure that intention-to-treat and missing data are properly reported in trial reports.
Representation of Ethics in the Plastic Surgery Literature: A Systematic Review
Authors: Chappell Ava G. , Kane Robert L. , Wood Shannon M. , Wescott Annie B. , Chung Kevin C.
Published: July 2021

Background:

A 2009 systematic review demonstrated that ethical discourse was underrepresented in the plastic surgery literature; approximately one in 1000 articles contained ethical discussions. In the decade since, advances in plastic surgery and continued social progress have created new ethical dilemmas. However, it is unclear whether these developments have augmented the representation of ethics in the plastic surgery literature. A review of publications over the past decade can assess whether progress has been made and identify where deficits persist.

Methods:

The authors searched eight bibliographic databases to identify peer-reviewed articles discussing ethical issues in plastic surgery over the past decade. Independent reviewers extracted characteristics and ethical principles from included articles.

Results:

A total of 7097 articles were identified from the initial search and 531 articles were included for analysis. The principle of autonomy, present in 87.9 percent of articles, had the greatest representation, followed by beneficence (74.4 percent), nonmaleficence (72.3 percent), and justice (51.2 percent). Informed consent and face transplantation were the most prevalent topics discussed. Aesthetic surgery was the subdiscipline of plastic surgery with the greatest ethical discourse, representing 29.8 percent of all included articles.

Conclusions:

In the past decade, there was approximately a five-fold increase in plastic surgery publications that include ethical discourse, indicating a growing awareness of ethical implications by the plastic surgery community. However, representation of ethical principles remained uneven, and specific subdisciplines of plastic surgery were substantially underrepresented. Plastic surgeons should adopt a more comprehensive approach when framing ethical implications in clinical and research settings.
Brief Report: Representations and Willingness of People Living With HIV in Switzerland to Participate in HIV Cure Trials: The Case of Gene-Modified Cell Therapies
Authors: Gilles Ingrid , Lesage Saphir , Barbieux Charlotte , Alessandrini Marco , Jackson-Perry David , Vittoz Lucie , Peytremann-Bridevaux Isabelle , Calmy Alexandra
Published: July 2021

Background:

Recent advances made in cell and gene therapies for cancer suggest that they represent plausible strategies to cure HIV. However, the health risks and constraints associated with these therapies require a deeper understanding of the expectations of such treatments among people living with HIV (PLWH).

Methods:

We conducted 15 semistructured in-depth interviews among patients from 2 HIV units in Switzerland. After a conversation about their perceptions of research on HIV therapies, participants were provided with a trial description using a gene-modified cell therapy as a potentially curative approach. They were invited to discuss how they might consider participation in the trial. Content analysis was performed to identify core themes.

Results:

Participants perceived the trial as burdensome and uncertain. Most were aware that cure was not guaranteed, and 6 of the 15 considered that they would participate. Two main concerns were expressed about potential participation: (1) the impact on the professional life and fear to be stigmatized because of this and (2) the fact that stopping antiretroviral treatment would challenge the balance currently achieved in their lives. The decision to participate would depend on their understanding of the trial, the availability of sufficient information, and the relationship with health care professionals.

Conclusion:

Involving PLWH in early stages of research would be crucial to improve their understanding of gene-modified cell therapies. It could also help adapt trials to address key factors, including the anticipation of stigma, which may discourage PLWH from participating in treatment research.
Transient Changes in Preexposure Prophylaxis Use and Daily Sexual Behavior After the Implementation of COVID-19 Restrictions Among Men Who Have Sex With Men
Authors: Jongen Vita W. , Zimmermann Hanne M. L. , Boyd Anders , Hoornenborg Elske , van den Elshout Mark A. M. , Davidovich Udi , van Duijnhoven Yvonne T. H. P. , de Vries Henry J C. , Prins Maria , Schim van der Loeff Maarten F. , Coyer Liza ,   on behalf of the Amsterdam PrEP Project team in the HIV Transmission Elimination Amsterdam Initiative
Published: July 2021

Background:

We assessed how the Dutch restrictions imposed on March 15, 2020, affected sexual behavior, preexposure prophylaxis (PrEP), and condom use among PrEP users in Amsterdam.

Methods:

We used data on (1) PrEP use, (2) anal sex acts, and (3) condom use, per partner type [steady partners (SPs), known casual partners (KCPs), and unknown casual partners (UCPs)], collected daily through a mobile application used between December 1, 2019, and June 30, 2020. We compared the period before versus after March 15, 2020, regarding average proportion of days per week at which each end point was reported and average proportion of anal sex acts covered by PrEP and/or condoms.

Results:

We included data from 136 men who have sex with men. After March 15, 2020, the proportion of days with anal sex increased with SPs [odds ratio (OR) = 1.26; 95% confidence interval (CI) = 1.10 to 1.44) and decreased with KCPs (OR = 0.73; 95% CI = 0.64 to 0.82) and UCPs (OR = 0.54; 95% CI = 0.48 to 0.61). Shifts in partner types were most profound immediately after March 15, 2020, whereas returning to prerestriction levels mid-May 2020. The proportion of days with PrEP use decreased from 74% before to 58% after March 15, 2020 (P < 0.001). After March 15, 2020, PrEP use during sex decreased with UCPs (β = −0.36; 95% CI = −0.72 to 0.00) but not with SPs and KCPs. Condom use during sex decreased with KCPs (β = −0.36; 95% CI = −0.67 to 0.04) and UCPs (β = −0.24; 95% CI = −0.46 to 0.03) but not with SPs.

Conclusions:

MSM decreased sex with casual partners and increased sex with SP, but changes were transient. Decreases in sex acts with casual partners paralleled decreases in PrEP use. However, condom use during sex with casual partners decreased, indicating the importance of continued sexual health services, including sexually transmitted infections screening and PrEP care, during COVID-19 restrictions.
A Systematic Review Comparing Outcomes of Local Flap Options for Reconstruction of Pressure Sores
Authors: Vathulya Madhubari , Praveen A.J. , Barik Sitanshu , Jagtap Manish Pradip , Kandwal Pankaj
Published: July 2021

Introduction

Pressure sores are agonizing complications of chronically bedridden patients. The management of these lesions particularly with respect to grades III and IV lesions are chiefly surgical and involves a multidisciplinary approach. Although there are a variety of local flap options, like fasciocutaneous flaps, musculocutaneous flaps, perforator flaps, and combinations of these to choose from, there is a paucity of literature regarding which flap is better among these in terms of complication and recurrence rates.

Methods

The databases searched were as follows: Cochrane Central Register of Controlled trials (January 2000 to July 2020), MEDLINE (January 2000 to July 2020), and EMBASE (January 2000 to August of 2020). Key words used were “pressure ulcer,” “flaps,” “surgery,” “pressure sore” with limits, “human,” and “English.” Primary outcomes were “overall complication rates” and “recurrence rates.” Overall complication was further categorized as flap necrosis, flap dehiscence, infection, and others.

Results

Thirty-nine articles were included in the final analysis. There was a statistically significant difference among the various types of flaps for overall complication, flap dehiscence, infection, flap necrosis, and recurrence rates.

Conclusions

Our study indicates that musculocutaneous flaps have lower recurrence rates, and combined flaps have lower complication rates. However, various other factors, like donor site morbidity, initial defect size, operating time, intraoperative blood loss, salvage options in case of recurrence, should also be considered while choosing a flap to reconstruct a defect.
Chemoradiation and Local Excision Versus Total Mesorectal Excision for T2N0 Rectal Cancer
Authors: Lynn Patricio B. , Van der Valk Maxime J.M. , Claassen Yvette H.M. , Shi Qian , Widmar Maria , Bastiaannet Ester , Van de Velde Cornelis J.H. , Garcia-Aguilar Julio
Published: July 2021

Objective:

Compare oncological long-term and short-term outcomes between patients with distal cT2NO rectal cancer treated with chemoradio-therapy and local excision (CRT + LE) and patients treated with total mesorectal excision (TME).

Summary Background Data:

Previous studies showed that CRT + LE is equivalent to TME in local tumor control and survival for T2N0 rectal cancer.

Methods:

Seventy-nine patients with cT2N0 rectal adenocarcinoma treated with CRT + LE in the ACOSOG Z6041 trial were compared to a cohort of 79 patients with pT2N0 tumors treated with upfront TME in the Dutch TME trial. Survival, short-term outcomes, and health-related quality of life (HRQOL) were compared between groups.

Results:

Three patients (4%) in the CRT + LE group required abdominoperineal resection, compared with 31 (40%) in the TME group. Forty TME patients (51%) required a permanent stoma. CRT-related toxicity occurred in 43% of the CRT + LE patients; however, TME patients had a higher rate of complications requiring reoperation (1 vs 9%; P = 0.03). Five-year disease-free survival {88.2% [confidence interval (CI), 77.7%–93.9%] vs 88.3% [CI, 78.7%–93.7%]; P = 0.88} and overall survival [90.3% (CI, 80.8%–95.3%) vs 88.4% (CI, 78.9%–93.8%); P = 0.82] were similar in the 2 groups. Compared to baseline, overall HRQOL decreased in the CRT + LE group and improved in the TME group. In both groups, patients with sphincter preservation had worse HRQOL scores 1 year after surgery. Conclusions: In patients who underwent CRT + LE, oncological outcomes were similar to those of patients who underwent TME, with fewer complications requiring reoperation but significant CRT toxicity. Although overall HRQOL decreased in the CRT + LE group and improved in TME patients, when considering anorectal function, results were worse in both groups.
Developing a measure of overall intensity of injury care: A latent class analysis
Authors: Zebrowski Alexis M. , Hsu Jesse Y. , Holena Daniel N. , Wiebe Douglas J. , Carr Brendan G.
Published: July 2021

BACKGROUND

While injury is a leading cause of death and debility in older adults, the relationship between intensity of care and trauma remains unknown. The focus of this analysis is to measure the overall intensity of care delivered to injured older adults during hospitalization.

METHODS

We used Centers for Medicare and Medicaid Services Medicare fee-for-service claims data (2013–2014), to identify emergency department–based claims for moderate and severe blunt trauma in age-eligible beneficiaries. Medical procedures associated with care intensity were identified using a modified Delphi method. A latent class model was estimated using the identified procedures, intensive care unit length of stay, demographics, and injury characteristics. Clinical phenotypes for each class were explored.

RESULTS

A total of 683,398 cases were classified as low- (73%), moderate- (23%), and high-intensity care (4%). Greater age and reduced injury severity were indicators of lower intensity, while males, non-Whites, and nonfall mechanisms were more common with high intensity. Intubation/mechanical ventilation was an indicator of high intensity and often occurred with at least one other procedure or an extended intensive care unit stay.

CONCLUSION

This work demonstrates that, although heterogeneous, care for blunt trauma can be evaluated using a single novel measure.

LEVEL OF EVIDENCE

For prognostic/epidemiological studies, level III.
Evaluation of hemostatic capacities among commando candidates: Would their blood suit a hemorrhagic war-injured patient in case of blood donation on the battlefield?
Authors: Daniel Yann , Conort Sébastien , Foricher Rachel , Hejl Carine , Travers Stéphane , Foissaud Vincent , Martinaud Christophe
Published: July 2021

BACKGROUND

In case of a warm fresh whole blood transfusion on the battlefield, the blood donation usually occurs just after a combat phase and often after several days on the fields. To explore the hemostatic capacity of such blood, we analyzed the blood of volunteers attending the commando course of the French Navy, considering this course as an experimental model, placing them into the same physiological conditions as those faced by deployed fighters.

METHODS

Venous blood was collected at the beginning of the course, mimicking their baseline status, and a second time 6 weeks later, from the remaining candidates, during the actual commando training, mimicking the stress conditions. For each candidate, we observed the differences between the two blood samples.

RESULTS

Of the 112 men that attended the first day of the course, only 17 remained 6 weeks later. In the second blood samples, we noted significant increased leucocytes and platelets counts and significant decreased hematocrit and hemoglobin levels. Thrombin generation assays showed significantly lower normalized peak heights (−31%), lower normalized endogenous thrombin potential values (−29%), and lower velocity index (−35%). Normalized lag time and time to peak did not differ. Viscoelastometric testing revealed a significant increasing in clot firmness as assessed by maximum amplitude and amplitude at 6 minutes. The clot speed was significantly increased.

CONCLUSION

This work brings new data on coagulation during prolonged and considerable physical exercise. No obvious deleterious modification of hemostatic properties was observed. The decrease of the endogenous thrombin potentials may reflect a better ability to control the thrombin generation once started. Altogether, these results suggest that this blood could suit well a hemorrhagic war-injured patient.

LEVEL OF EVIDENCE

Prospective observational cohort study, Level III.