bluuebunny/crossref_metadata_2025 huggingface dataset:
The Use of Standardized Patients to Increase Medical Student Awareness of and Confidence in Screening for Human Trafficking
Authors: Mercer Laura , Ludwig Amy , Smith Jeremi , Erickson Laurie , Manriquez Maria
Published: September 2018

Local Mentor:

Laurie Erickson, MD

APGO Advisor:

Jody Steinauer, MD, MAS

PROBLEM:

Human trafficking is a growing problem, but is often unrecognized. Victims are frequently kept in isolation with little freedom and autonomy, limiting their access to resources and recovery. Skilled health care providers can be the first to intervene on the victim’s behalf. A healthcare provider’s knowledge of the signs/symptoms of trafficking, the use of skillful communication techniques, and a familiarity of the patient's rights and resources are vital.

INTERVENTION:

Medical students are assigned a web-based independent learning module about human trafficking, its signs and symptoms, intervention strategies, and resources. Each student then participates in a simulation with a standardized patient (SP) who is a victim of trafficking, a detail the student must uncover with history taking. They then complete reflective writing, receive individual feedback from the SP, and participate in a group faculty/peer debrief session.

CONTEXT:

The intervention occurs at the University of Arizona College of Medicine – Phoenix during the required OBGYN clerkship, with the standardized patient and follow-up experiences occurring during the final week of the six-week clerkship.

OUTCOME/LESSONS LEARNED:

Comparing pre-and post-intervention surveys of medical students identified a significant rise in confidence both in their ability to identify and also support victims of sex trafficking. In reflective essays, students most often feel sad, disappointed, or helpless during the SP encounter, but they remain committed develop rapport, provide resources, and empower their patient. These findings suggest that this is an effective educational intervention to teach medical students about sex trafficking.
Hysteroscopic Resection Training Utilizing a Virtual Reality and Low Fidelity Model: A Pilot Study
Authors: Patel Nima R. , Johnson Christina M. , Makai Gretchen E.
Published: September 2018

Faculty Advisor:

Amy Boardman, MD

PURPOSE:

To evaluate effectiveness of Virtual Reality (VR) and low-fidelity inanimate model for training OB/GYN residents in hysteroscopic resection.

BACKGROUND:

While surgical training in gynecology is often accomplished through supervision in the operating room, simulation allows risk-free surgical skills practice. VR and low-fidelity models provide training of different surgical procedures, which could improve resident confidence and knowledge with less common procedures. As mechanical resection device use continues to increase, residents have fewer opportunities to train with hysteroscopic resectoscopes.

METHODS:

This prospective, cohort trial at Christiana Care, a large community hospital, enrolled 24 PGY1-4 OBGYN residents. All participants served as their own controls and underwent pre-intervention objective skills assessment testing (OSAT) for hysteroscopic resection using a low-fidelity potato model. Intervention included completion of a VR hysteroscopic simulator module to achieve a score >95%. Participants then underwent immediate post-intervention OSAT. All participants completed a subjective survey assessing comfort levels with the procedure pre- and post-intervention. All low-fidelity hysteroscopic resections were recorded and scored by a single, blinded evaluator.

RESULTS:

Seven OSAT surgical skills and subjective measures were assessed using a Likert Scale of 1 (low) to 5 (high). PGY 3&4 residents showed improvement in camera management, tissue handling, and instrument management (P=<.05). Three-month repeat OSATs showed retention of the same skills plus flow of procedure in all residents. Subjectively, there was significant improvement in comfort level of knowledge of procedural steps and energy, and using the loop resectoscope.

DISCUSSION:

Simulation improved baseline surgical skills and led to retention and improvement of same skills. Resident training should include simulation to increase both baseline development and retention of surgical skills.
Imaging of Cat Scratch Disease
Authors: Amin Sagar B. , Sharma Priya G. , Rajderkar Dhanashree A.
Published: September 2018

Cat scratch disease is caused by the inoculation of Bartonella henselae, a gram-negative bacterium, by either a bite or a scratch from an insect or a cat, and it most frequently occurs in adolescence. Cat scratch disease most commonly presents with fever, headache, fatigue, and tender regional lymphadenopathy that subsides in several weeks, with or without antibiotics. However, in 5% to 10% of patients, cat scratch disease may disseminate to involve multiple organ systems and mimic more serious systemic conditions both clinically and radiologically, requiring a more in-depth investigation.1 This article presents the common and rare imaging features of regional and multiorgan cat scratch disease using a multimodality imaging approach. We highlight key characteristics so that they may become more recognizable to the radiologist.
Diabetic autonomic neuropathy resulting in sexual dysfunction
Authors: Wooton Angela K. , Melchior Lynne M.
Published: September 2018

Although diabetic autonomic neuropathy (DAN), a complication associated with diabetes, is increasing in prevalence, it is often overlooked. Knowledge regarding the development and progression of this complication is limited. NPs are in a key position to prevent complications of DAN, including sexual dysfunction, in this vulnerable population.
Improving Employee Voice About Transgressive or Disruptive Behavior: A Case Study
Authors: Dixon-Woods Mary , Campbell Anne , Martin Graham , Willars Janet , Tarrant Carolyn , Aveling Emma-Louise , Sutcliffe Kathleen , Clements Janice , Carlstrom Michelle , Pronovost Peter
Published: September 2018

Purpose

Employee voice plays an important role in organizational intelligence about patient safety hazards and other influences on quality of patient care. The authors report a case study of an academic medical center that aimed to understand barriers to voice and make improvements in identifying and responding to transgressive or disruptive behaviors.

Method

The case study focused on an improvement effort at Johns Hopkins Medicine that sought to improve employee voice using a two-phase approach of diagnosis and intervention. Confidential interviews with 67 individuals (20 senior leaders, 47 frontline personnel) were conducted during 2014 to diagnose causes of employee reluctance to give voice about behavioral concerns. A structured intervention program to encourage voice was implemented, 2014–2016, in response to the findings.

Results

The diagnostic interviews identified gaps between espoused policies of encouraging employee voice and what happened in practice. A culture of fear pervaded the organization that, together with widespread perceptions of futility, inhibited personnel from speaking up about concerns. The intervention phase involved four actions: sharing the interview findings; coordinating and formalizing mechanisms for identifying and dealing with disruptive behavior; training leaders in encouraging voice; and building capacity for difficult conversations.

Conclusions

The problems of giving voice are widely known across the organizational literature but are difficult to address. This case study offers an approach that includes diagnostic and intervention phases that may be helpful in remaking norms, facilitating employee voice, and improving organizational response. It highlights specific actions that are available for other organizations to adapt and test.
Beyond the Quality Illusion: The Learning Era
Authors: Koksma Jan-Jurjen , Kremer Jan A.M.
Published: September 2018

By highlighting the intangible, personal, contextual, and illusory nature of “quality,” the authors reconceptualize quality improvement as a pluralistic and moral journey. They imagine a new era of quality improvement in which patients and health care providers work together to understand and achieve quality. The authors recommend, for the path forward, a “travel kit” of 10 crucial elements—compassion, deliberation, flexible goals, ownership, the engagement of patients, the inclusion of payers, the involvement of learners, feedback loops, the fostering of learning, and the application of different sources of knowledge—to reframe quality improvement in a new era of learning.
Data, Big and Small: Emerging Challenges to Medical Education Scholarship
Authors: Ellaway Rachel H. , Topps David , Pusic Martin
Published: September 2018

The collection and analysis of data are central to medical education and medical education scholarship. Although the technical ability to collect more data, and medical education’s dependence on data, have never been greater, it is getting harder for medical schools and educational scholars to collect and use data, particularly in terms of the regulations, security issues, and growing reluctance of learners and others to participate in data collection activities. These two countervailing trends present a growing threat to the viability of medical education scholarship. In response, there must either be a more conducive data environment for medical education scholarship or medical education must move to become less dependent on data.

There is, therefore, a growing need for a system-wide correction: a shift in practice that makes data use more viable and productive while maintaining high professional standards. There are five core areas that can contribute to a system-wide correction: greater clarity over what can be used as data; greater clarity on what constitutes “good” data; changes to the ways in which data are collected; better strategic stewardship of existing data; and deliberate and strategic attention to “data readiness” in support of medical education and medical education scholarship. These solutions are primarily practical and conceptual changes in the face of what are mainly regulatory challenges. However, medical educators also need to engage with emerging areas of practice such as learning analytics, and they need to consider the shifting social contract for using data in medical education.
Medical Student- and Resident-Authored Publications in Academic Medicine From 2002 to 2016: A Growing Trend and Its Implications
Authors: Munzer Brendan W. , Griffith Max , Townsend Whitney A. , Burk-Rafel Jesse
Published: September 2018

Purpose

The extent of medical trainees’ engagement in scholarly medical education publication is not well described. This study sought to quantify the prevalence of medical student- and resident-authored medical education publications over 15 years, a benchmark essential for understanding current and future trends in trainee scholarship.

Method

Of 91 identified journals, 16 met inclusion criteria as indexed general medical education journals. Only Academic Medicine provided complete author role information, allowing identification of medical student and resident authors. The authors retrospectively compiled and analyzed citation records from Academic Medicine from 2002 to 2016, tracking trainee authorship, author position, and publication type.

Results

A total of 6,280 publications were identified, of which 4,635 publications, by 16,068 authors, met inclusion criteria. Trainees were 6.0% (966/16,068) of all authors and authored 14.5% (673/4,635) of all publications. Trainee authorship rates varied by publication type: Trainees authored 33.3% (160/480) of medical humanities publications versus 6.9% (27/392) of commentaries. From 2002–2004 to 2014–2016, the proportion of authors who were trainees increased from 3.9% (73/1,853) to 7.1% (330/4,632) (P < .001 for trend). Over the same period, the percentage of trainee-authored publications increased: 9.4% (58/620) to 18.8% (225/1,199) (P < .001 for trend), driven primarily by increased trainee first authorship.

Conclusions

Trainees constitute a small but growing proportion of authors and authored publications in Academic Medicine. Further work is needed to understand what trainee-, institutional-, and journal-level factors contribute to this trend, and whether similar increases in trainee authorship are occurring in other journals and fields.
The Integration of Clinical and Research Training: How and Why MD–PhD Programs Work
Authors: Ng Enoch , Jones Andrea A. , Sivapragasam Milani , Nath Siddharth , Mak Lauren E. , Rosenblum Norman D.
Published: September 2018

For over 60 years, MD–PhD programs have provided integrated clinical and research training to produce graduates primed for physician–scientist careers. Yet the nature of this integrated training is poorly characterized, with no program theory of MD–PhD training to guide program development or evaluation. The authors address this gap by proposing a program theory of integrated MD–PhD training applying constructs from cognitive psychology and medical education. The authors argue that integrated physician–scientist training requires development of at least three elements in trainees: cognitive synergy, sense of self, and professional capacity. First, integrated programs need to foster the cognitive ability to synergize and transfer knowledge between the clinical and research realms. Second, integrated programs need to facilitate development of a unique and emergent identity as a physician–scientist that is more than the sum of the individual roles of physician and scientist. Third, integrated programs should develop core competencies unique to physician–scientists in addition to those required of each independently. The authors describe how programs can promote development of these elements in trainees, summarized in a logic model. Activities and process measures are provided to assist institutions in enhancing integration. Specifically, programs can enact the proposed theory by providing tailored MD–PhD curricula, personal development planning, and a supportive community of practice. It is high time to establish a theory behind integrated MD–PhD training as the basis for designing interventions and evaluations to develop the foundations of physician–scientist expertise.
Key Factors in Clinical Competency Committee Members’ Decisions Regarding Residents’ Readiness to Serve as Supervisors: A National Study
Authors: Schumacher Daniel J. , Martini Abigail , Bartlett Kathleen W. , King Beth , Calaman Sharon , Garfunkel Lynn C. , Elliott Sean P. , Frohna John G. , Schwartz Alan , Michelson Catherine D.
Published: September 2018

Purpose

Entrustment has become a popular assessment framework in recent years. Most research in this area has focused on how frontline assessors determine when a learner can be entrusted. However, less work has focused on how these entrustment decisions are made. The authors sought to understand the key factors that pediatric residency program clinical competency committee (CCC) members consider when recommending residents to a supervisory role.

Method

CCC members at 14 pediatric residency programs recommended residents to one of five progressive supervisory roles (from not serving as a supervisory resident to serving as a supervisory resident in all settings). They then responded to a free-text prompt, describing the key factors that led them to that decision. The authors analyzed these responses, by role recommendation, using a thematic analysis.

Results

Of the 155 CCC members at the participating programs, 84 completed 769 supervisory role recommendations during the 2015–2016 academic year. Four themes emerged from the thematic analysis: (1) Determining supervisory ability follows from demonstrated trustworthiness; (2) demonstrated performance matters, but so does experience; (3) ability to lead a team is considered; and (4) contextual considerations external to the resident are at play.

Conclusions

CCC members considered resident and environmental factors in their summative entrustment decision making. The interplay between these factors should be considered as CCC processes are optimized and studied further.
Measuring Clinical Productivity of Anesthesiology Groups
Authors: Abouleish Amr E. , Hudson Mark E. , Whitten Charles W.
Published: September 2018

Benchmarking and comparing group productivity is an essential activity of data-driven management. For clinical anesthesiology, accomplishing this task is a daunting effort if meaningful conclusions are to be made. For anesthesiology groups, productivity must be done at the facility level in order to reduce some of the confounding factors. When industry or external comparisons are done, then the use of total ASA units per anesthetizing sites allows for overall productivity comparisons. Additional productivity components (total ASA units/h, h/case, h/operating room/d) allow for leaders to develop productivity dashboards. With the emergence of large groups that provide care in multiple facilities, these large groups can choose to invest more effort in collecting data and comparing facility productivity internally with group-defined measurements including total ASA units per full time equivalent.
Association Between Gestational Weight Gain and Perinatal Outcomes
Authors: Kominiarek Michelle A. , Saade George , Mele Lisa , Bailit Jennifer , Reddy Uma M. , Wapner Ronald J. , Varner Michael W. , Thorp John M. , Caritis Steve N. , Prasad Mona , Tita Alan T.N. , Sorokin Yoram , Rouse Dwight J. , Blackwell Sean C. , Tolosa Jorge E. ,   for the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network
Published: September 2018

OBJECTIVE:

To evaluate the association between gestational weight gain and maternal and neonatal outcomes in a large, geographically diverse cohort.

METHODS:

Trained chart abstractors at 25 hospitals obtained maternal and neonatal data for all deliveries on randomly selected days over 3 years (2008–2011). Gestational weight gain was derived using weight at delivery minus prepregnancy or first-trimester weight and categorized as below, within, or above the Institute of Medicine (IOM) guidelines in this retrospective cohort study. Maternal (primary or repeat cesarean delivery, third- or fourth-degree lacerations, severe postpartum hemorrhage, hypertensive disease of pregnancy) and neonatal (preterm birth, shoulder dystocia, macrosomia, hypoglycemia) outcomes were compared among women in the gestational weight gain categories in unadjusted and adjusted analyses with odds ratios (ORs) and 95% CI reported. Covariates included age, race-ethnicity, tobacco use, insurance type, parity, prior cesarean delivery, pregestational diabetes, hypertension, and hospital type.

RESULTS:

Of the 29,861 women included, 51% and 21% had gestational weight gain above and below the guidelines, respectively. There was an association between gestational weight gain above the IOM guidelines and cesarean delivery in both nulliparous women (adjusted OR 1.44, 95% CI 1.31–1.59) and multiparous women (adjusted OR 1.26, 95% CI 1.13–1.41) and hypertensive diseases of pregnancy in nulliparous and multiparous women combined (adjusted OR 1.84, 95% CI 1.66–2.04). For the neonatal outcomes, gestational weight gain above the IOM guidelines was associated with shoulder dystocia (adjusted OR 1.74, 95% CI 1.41–2.14), macrosomia (adjusted OR 2.66, 95% CI 2.03–3.48), and neonatal hypoglycemia (adjusted OR 1.60, 95% CI 1.16–2.22). Gestational weight gain below the guidelines was associated with spontaneous (adjusted OR 1.50, 95% CI 1.31–1.73) and indicated (adjusted OR 1.34, 95% CI 1.12–1.60) preterm birth.

CONCLUSION:

In a large, diverse cohort with prospectively collected data, gestational weight gain below or above guidelines is associated with a variety of adverse pregnancy outcomes.
Intrapartum Fetal Heart Rate Tracing Among Small-for-Gestational Age Compared With Appropriate-for-Gestational-Age Neonates
Authors: Chauhan Suneet P. , Weiner Steven J. , Saade George R. , Belfort Michael A. , Reddy Uma M. , Thorp John M. , Tita Alan T. N. , Miller Russell S. , Dinsmoor Mara J. , McKenna David S. , Stetzer Bradley , Rouse Dwight J. , Gibbs Ronald S. , El-Sayed Yasser Y. , Sorokin Yoram , Caritis Steve N. ,   for the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network
Published: September 2018

OBJECTIVE:

To compare fetal heart rate (FHR) patterns during the last hour of labor between small-for-gestational-age (SGA; birth weight less than the 10th percentile for gestational age) and appropriate-for-gestational-age (AGA; birth weight at the 10–90th percentile) neonates at 36 weeks of gestation or greater. We also compared the rate of cesarean delivery and composite neonatal morbidity among SGA and AGA newborns.

METHODS:

This is a secondary analysis of a randomized trial of intrapartum fetal electrocardiographic ST-segment analysis. We excluded women with chorioamnionitis, insufficient duration of FHR tracing in the hour before delivery, and anomalous newborns. Fetal heart rate patterns were categorized by computerized pattern recognition software (PeriCALM Patterns). Composite neonatal morbidity was defined as any of the following: intrapartum fetal death, Apgar score 3 or less at 5 minutes, cord artery pH 7.05 or less, base deficit 12 mmol/L or greater, neonatal seizure, intubation at delivery, neonatal encephalopathy, and neonatal death. Logistic regression was used to evaluate the association between FHR patterns and SGA adjusted for magnesium sulfate exposure and stage of labor.

RESULTS:

Of the 11,108 women randomized, 85% (n=9,402) met inclusion criteria, of whom 9% were SGA. In the last hour, the likelihood of accelerations was significantly lower among SGA than AGA neonates (72.4% vs 66.8%; P=.001). Variable decelerations lasting greater than 60 seconds, with depth greater than 60 beats per minute (bpm) or nadir less than 60 bpm, were significantly more common with SGA than AGA (all P<.001). The rate of late decelerations, prolonged decelerations, or bradycardia were similar between SGA and AGA (all P>.05). Cesarean delivery for fetal indications was significantly more common with SGA (7.0%) than AGA (4.0%; P<.001). The composite neonatal morbidity was 1.4% among SGA and 1.0% among AGA (odds ratio 1.40, 95% CI 0.74–2.64).

CONCLUSION:

Although the FHR patterns in the last hour of labor differ among SGA and AGA neonates, as does the rate of cesarean delivery, the composite neonatal morbidity was similar.
Development and Validation of a Simulation Model for Laparoscopic Colpotomy
Authors: Frazzini Padilla Pamela M. , Farag Sara , Smith Katherine A. , Zimberg Stephen E. , Davila G. Willy , Sprague Michael L.
Published: September 2018

OBJECTIVE:

To develop a realistic simulation model for performance of laparoscopic colpotomy and evaluate its construct and face validity.

METHODS:

A simulation model was developed and constructed using polyvinyl chloride piping, a uterine manipulator, and synthetic vaginal tissue paired with a commercially available laparoscopic trainer. An observational study was conducted to validate the simulation model for use as a teaching tool. Construct validity was measured through performance evaluation of novice and expert surgeons using a standard and modified Global Operative Assessment of Laparoscopic Skills scale with possible score ranges of 5–25 and 5–40, respectively. Expert surgeons included attending surgeons across various gynecologic subspecialties who teach total laparoscopic hysterectomy to trainees and perform more than 50 total laparoscopic hysterectomies annually. Novice surgeons included residents who perform total laparoscopic hysterectomy as part of their training. Standards were set using a modified contrasting groups approach. Interrater reliability was calculated using Kendall’s τ correlation coefficient. Participants were surveyed regarding the realism of the model and its utility as a teaching tool to assess face validity.

RESULTS:

Five expert and 15 novice surgeons volunteered to participate. Expert surgeons scored higher than novice surgeons on the Global Operative Assessment of Laparoscopic Skills scale (22.8±1.52 vs 13.53±2.69, respectively) with a mean difference of 9.27 (95% CI 7.12–11.4, P<.01) and on a modified Global Operative Assessment of Laparoscopic Skills scale (36.9±2.19 vs 22.6±3.95, respectively) with a mean difference of 14.30 (95% CI 11.2–17.4, P<.01). Suggested passing range was set at 30.5–32.5 out of 40 total points. Kendall’s τ interrater reliability was 0.86 (95% CI 0.798–0.923) and 0.87 (95% CI 0.818–0.922), respectively. All participants agreed that the training model was useful for teaching and learning laparoscopic colpotomy and for assessing the learner’s ability to perform colpotomy before live surgery.

CONCLUSION:

This validated simulation system offers novice surgeons an opportunity to practice the skill set necessary to perform laparoscopic colpotomy efficiently and may be used as an educational tool.
Beyond Silence and Inaction
Authors: Premkumar Ashish , Whetstone Sara , Jackson Andrea V.
Published: September 2018

The issue of race and ethnicity within obstetrics and gynecology has come to the forefront in the current social and political climate. Understanding the ill effects of racism within the clinical space requires an acknowledgment of both the ongoing problem and current limitations in the state of knowledge and praxis among clinicians, trainees, and educators alike. In this commentary, the issue of race and racism within obstetrics and gynecology is discussed through a case of discrimination experienced by an intern working in an urban, academic hospital. By attending to the different layers of hierarchy within medical education and care as well as the multitude of silences from potential allies, we demonstrate a critical need to understand racism and inequality in the clinical and educational space. We deconstruct the issue of race and racism by contextualizing it with ongoing discussions in the social sciences and public health as well as wider discussions of the relationship of race with professional training and employment in biomedical fields. Finally, we offer both action items and calls for future educational and practice-based solutions to affect change in the way obstetrics and gynecology is taught and practiced.
T cells and cytokines in systemic sclerosis
Authors: Fuschiotti Patrizia
Published: September 2018

Purpose of review

Dysregulation of both the innate and the adaptive immune systems has been identified in systemic sclerosis (SSc). However, the mechanisms underlying aberrant immune cell function remain poorly understood. T cells represent a predominant cell type in the affected tissues of patients, particularly in the early inflammatory stage of the disease. Antigen specificity of infiltrating T cells has not been identified; however, recent studies implicate specific T-cell subsets and the cytokines they produce in SSc pathogenesis by modulating the development of autoimmunity, inflammation and fibrosis.

Recent findings

The phenotype and function of distinct T-cell subsets have been identified in the affected tissues of SSc patients as well as in SSc animal models, implying their contribution to disease process. The molecular mechanisms underlying cytokine dysregulation by specific T-cell subpopulations are also becoming clear.

A better understanding of SSc pathogenesis will allow the development of novel therapeutic strategies targeting specific cell types and the pathways that are abnormally activated as well as the cytokines produced that may be directly involved with disease process. A further goal is to tailor therapy to address dysregulation specific to individual patients, leading to better efficacy and reduced toxicity.
Antisynthetase syndrome pathogenesis: knowledge and uncertainties
Authors: Gallay Laure , Gayed Catherine , Hervier Baptiste
Published: September 2018

Purpose of review

Antisynthetase syndrome (ASyS) is an acquired myopathy characterized by the presence of myositis-specific autoantibodies directed against tRNA-synthetases. ASyS is potentially life threatening due to lung involvement and treatment remains a challenge to date. With symptoms not limited to muscles but also involving lung, skin and joints, ASyS appears specific and has a particular pathogenesis, different from the other inflammatory myopathies. This review is intended to discuss the current understanding of ASyS pathogenesis, pointing its current knowledge and also the crucial prospects that may lead to critical improvement of ASyS care.

Recent findings

Regarding ASyS pathogenesis, initiation of the disease seems to arise in a multifactorial context, with first lesions occurring within the lungs. This may lead to aberrant self-antigen exposure and tolerance breakdown. The consequences are abnormal activation of both innate and adaptive immunity, resulting in the patients with favourable genetic background to autoimmune-mediated organ lesions. Immune and nonimmune roles of the antigen, as well as antigen presentation leading to specific T-cell and B-cell activation and to the production of specific autoantibodies belong to the disease process.

This work aims to detail ASyS pathogenesis understanding, from initiation to the disease propagation and target tissue lesions, in order to considering future treatment directions.
Rate of Open Reduction for Supracondylar Humerus Fractures Varies Across Pediatric Orthopaedic Surgeons: A Single-Institution Analysis
Authors: DeFrancesco Christopher J. , Shah Apurva S. , Brusalis Christopher M. , Flynn Kelly , Leddy Kelly , Flynn John M.
Published: September 2018

Objectives:

To (1) define a single institution's rate of open reduction for operative pediatric supracondylar humerus (SCH) fractures; (2) describe variability by surgeon in rates of irreducible fracture (IRF) and open reduction; and (3) determine whether variation in opening rate correlated with surgeon experience.

Design:

Retrospective analytic study.

Setting:

Urban tertiary care Level 1 trauma center.

Patients/Participants:

Twelve fellowship-trained pediatric orthopaedists.

Main Outcome Measurements:

Rate of open reduction for operatively treated SCH fractures (OTA/AO 13-M/3).

Results:

One thousand two hundred twenty-nine type II SCH fractures (none of which required open reduction) were excluded from the analysis. A total of 1365 other SCH fractures were included: 1302 type III fractures, 27 type IV fractures, and 36 fractures with unspecified type. 2.9% of type III and 22.2% of type IV fractures required open reduction. None of the injuries with unspecified type required open reduction. The rate of open reduction among 11 surgeons ranged from 0% to 15.0% in type III–IV fractures (P = 0.001). 86% (38/44) of open reductions were performed for IRF. In regression analysis, patient age was associated with open reduction for IRF (odds ratio 1.22, P = 0.001), but surgeon years-in-practice (0.321) and number of previous cases (0.327) were not associated with open reduction. Other indications for opening included suspected vascular or neurologic injury.

Conclusions:

Open reduction was rarely performed in this sample, but IRF was the dominant indication for opening. We found true variation in surgeons' rates of performing open reductions. More experience was not correlated with decreased likelihood of open reduction.

Level of Evidence:

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Partnership in Ethiopia: University of Utah's and UCLA's Departments of Orthopaedics Collaboration With Soddo Christian Hospital in Ethiopia
Authors: Anderson Lucas A. , Bernthal Nicholas M. , Haller Justin M. , Higgins Thomas F. , Elliott Iain S. , Anderson Duane R.
Published: September 2018

Collaborations between orthopaedic training programs in developed countries and international sites in austere environments offer abundant benefits and mutual enrichment. It is often assumed that the exchange is one-sided and we hope to dispel that assumption. Despite the logistical challenges inherent in these partnerships, our experience has been unanimously reviewed as “greatly beneficial” to visiting residents/faculty and surgeons/trainees at the host location. We hope that this article will (1) encourage faculty at training programs to permit and enable residents to experience international orthopaedics while still in training; (2) encourage faculty to visit international hospitals while contributing expertise in subspecialty surgery, research, and teaching; and (3) encourage international hospitals to create opportunities for clinical and research collaboration with academic orthopaedics departments.
Perceptions of Orthopaedic Volunteers and Their Local Hosts in Low- and Middle-Income Countries: Are We on the Same Page?
Authors: Wassef David W. , Holler Jordan T. , Pinner April , Challa Sravya , Xiong Meng , Zhao Caixia , Sabharwal Sanjeev
Published: September 2018

Objective:

Our goal was to compare the perceptions of overseas orthopaedic volunteers and their hosts in low- and middle-income countries (LMICs) regarding the role of international volunteerism. We also sought to determine if differences in perception exist between trainee and fully trained orthoapedic surgeon volunteers.

Methods:

Surveys with similar multiple-choice and open-ended questions were administered to 163 Health Volunteers Overseas orthopaedic volunteers (response rate 45%) and 53 members of the host orthopaedic staff (response rate 40%). Fifty-four volunteers and 20 hosts also contributed open-ended responses. Quantitative responses were analyzed for significance using Mantel–Haenzel χ2 tests. Open-ended responses were coded using thematic analysis.

Results:

Both the international volunteers and their LMIC hosts agreed that volunteers learned new skills while volunteering. Both groups believed that international volunteerism had a positive overall impact on the local practice, but hosts viewed these benefits more favorably than volunteers did. LMIC staff believed that, besides altruistic reasons, volunteers were also motivated by professional gains, diverging from volunteer responses. In open-ended responses, hosts desired longer term commitments from volunteers and had some concerns regarding volunteers' qualifications. Between volunteer trainees and fully trained surgeons, trainees were more likely to be motivated by personal benefits.

Conclusion:

Efforts must be made to further align the expectations and goals of volunteers and their hosts in LMICs. Certain measures such as predeparture orientations for volunteers and developing a more longitudinal and bidirectional experience may enhance the impact of orthopaedic volunteerism in LMICs. Further studies are needed to explore the impact of international orthopaedic volunteerism on the host population.
Treatment of tibial deformities with the Fassier–Duval telescopic nail and minimally invasive percutaneous osteotomies in patients with osteogenesis imperfecta type III
Authors: Persiani Pietro , Ranaldi Filippo Maria , Martini Lorena , Zambrano Anna , Celli Mauro , D’Eufemia Patrizia , Villani Ciro
Published: September 2018

Osteogenesis imperfecta (OI) is a rare congenital osteodystrophy. Patients with OI present with osteoporosis, extreme bone fragility and severe deformities of the lower limbs, which predispose them to frequent fractures. The aim of our study is to describe the minimally invasive osteotomy technique to correct the tibial deformities in patients with OI type III, using the Fassier–Duval (FD) intramedullary nailing, which is considered the gold standard in this kind of surgery. We analyzed the results obtained from 14 patients with OI type III, treated for tibial deformities with the minimally invasive percutaneous osteotomy technique and osteosynthesis with the FD telescopic nail. The results were compared with that of a control group composed of 18 patients with OI type III, treated for tibial deformities with open technique osteotomies and osteosynthesis with FD telescopic nail. The follow-up was set at 18 months postoperatively. The data concerning the following were collected from the two groups: duration of surgery, number of osteotomies performed, postoperative pain, time required for functional recovery, and for the formation of bone callus. To analyze the variations in the quality of life, all the patients were given the Pediatric Outcomes Data Collection Instrument questionnaire, before surgery and at the end of the follow-up. In patients who underwent corrective surgery with the percutaneous technique, the average duration of surgery was inferior, the postoperative pain was significantly lower, the recovery of 90° range of motion of knee flexion was reached at an average of 37.8 days, and they ambulated bearing full weight on the leg without auxiliary aids on average 45 days after surgery. The Pediatric Outcomes Data Collection Instrument questionnaire values were satisfactory in both groups. The osteosynthesis with the FD telescopic nail, performed with the minimally invasive surgical technique, has improved the management of deformities in OI. The minimally invasive technique, however, requires the maturation of three distinct learning curves: surgery on patients with OI, open technique with the FD nail, and percutaneous technique with the FD nail.
The top 100 most-cited articles on ‘Clubfoot’
Authors: Malik Azeem T. , Noordin Shahryar
Published: September 2018

Clubfoot is an important aspect of pediatric orthopedics and is a readily prevalent condition presenting to orthopedic clinics worldwide. To identify landmark articles and important contributions to this field, we sought to do a citation analysis of the top 100 most-cited articles on clubfoot. Using the Scopus database and the search strategy ‘Clubfoot’, ‘Clubfeet’ OR ‘Talipes Equinovarus’, we identified 5753 articles. After filtering for relevant articles, the top 100 cited articles on clubfoot were retrieved for descriptive and statistical analysis. The most cited paper was ‘Long-term results of treatment of congenital clubfoot’ by S.J. Laaveg and I.V. Ponseti with 358 citations. The publication years ranged from 1969 to 2011. The USA was the most productive country in terms of research output, followed by the UK. Institution-wise, the University of Iowa contributed the most in terms of number of publications. The Journal of Pediatric Orthopaedics held the most number of articles. Most publications were level IV and level V studies. Although citation analysis has it flaws, this is a comprehensive list of the top 100 articles significantly affecting literature on clubfoot. On the basis our study, we conclude that there is marked deficiency of high-level articles with respect to the number of citations, and future researches need to cater to this question to produce high-quality studies.
Femoral trochlea does not remodel after patellar stabilization in children older than 10 years of age
Authors: Rajdev Neil R. , Parikh Shital N.
Published: September 2018

Trochlear dysplasia is a major risk factor for patellar instability. It has been sparsely reported that the trochlea can remodel when patellar stabilization is performed in skeletally immature patients before the age of 10 years. It is not known whether trochlea can remodel significantly after the age of 10 years. The purpose of the study was to evaluate trochlear remodeling in skeletally immature patients after patellar stabilization surgery, with a focus on children older than 10 years of age. In a retrospective study, knee MRI of 21 patients who had undergone patellar stabilization surgery, were evaluated. Twenty of these 21 patients were older than 10 years of age at time of surgery. The measurements of cartilaginous and bony sulcus angles, trochlear depth, and cartilaginous trochlear bump were compared between preoperative and postoperative MRI, using paired t-tests. In 20 patients older than 10 years of age, the mean cartilaginous sulcus angle change between preoperative and postoperative axial MRI was not significant (2.2°±7.9°, P=0.6). The mean change in the bony sulcus angle value was not significant (3.6°±6.8°, P=0.07). Similarly, there was no significant change in trochlear depth (P=0.8), or size of the trochlear bump (P=0.1). For one patient under 10 years of age at the time of surgery, there was a 21° and a 15° improvement in cartilaginous and bony sulcus angle, respectively. There were no significant changes in the trochlear parameters and trochlear remodeling in patients older than 10 years of age. Patellar stabilization at a younger age (<10 years), may allow for trochlear remodeling. Level of Evidence: Level IV, case series.
Pediatric obesity is associated with short-term risks after pelvic osteotomy
Authors: Basques Bryce A. , Meadows Molly C. , Grauer Jonathan N. , Kogan Monica
Published: September 2018

The risk factors for increased perioperative morbidity following pediatric pelvic osteotomies are poorly understood. The purpose of this study was to characterize differences in adverse events, operative time, length of stay, and readmission following pelvic osteotomy for obese and nonobese patients. A retrospective cohort study was carried out using the National Surgical Quality Improvement Program Pediatric database to identify patients that underwent pelvic osteotomy with or without femoral osteotomy. Obesity was found to be an independent risk factor for blood transfusion (relative risk: 1.4, P=0.007) and readmission (relative risk: 2.3, P=0.032) within 30 days. These data can facilitate patient counseling and informed decision-making when planning for surgical correction of hip dysplasia.
Normal value and range of the humerus–elbow–wrist angle in a sample of healthy children with even distributions of age, sex, and laterality
Authors: Inaba Naoto , Suzuki Taku , Iwamoto Takuji , Matsumura Noboru , Oki Satoshi , Nishiwaki Masao , Nakamura Masaya , Matsumoto Morio , Sato Kazuki
Published: September 2018

This study was performed to evaluate the normal value of the humerus–elbow–wrist angle (HEWA) in a sample of healthy children with even distributions of age, sex, and laterality. A total of 168 radiographs of the elbows of healthy children with even distributions of age, sex, and laterality were reviewed. The mean HEWA was 12.1° (range: 5°–20°). The value of HEWA was significantly associated with increasing age. Neither sex nor side showed significant differences for the HEWA. The data should be useful for postoperative radiographic assessment of cubitus varus or valgus deformities.
High rate of inappropriate referrals to pediatric orthopedics in an egalitarian healthcare system
Authors: Balazs George C. , Doria Ronald B. , Yow Bobby G. , Anderson Ashley B. , Ahmed Syed I. , Jex Jefferson W.
Published: September 2018

Previous studies have shown relatively high rates of inappropriate referrals to pediatric orthopedic surgery. The purpose of this study was to determine the rate of inappropriate referrals in an egalitarian healthcare system. We reviewed all 400 referrals to our pediatric orthopedic surgery practice over a 2-year period and assessed the appropriateness of each based on the American Academy of Pediatrics guidelines. A total 206 (52%) referrals were deemed appropriate. There is a high rate of inappropriate referral to pediatric orthopedic surgery even within a closed, egalitarian healthcare system. Targeted education of primary care providers may help reduce this rate.
Missed proximal radioulnar joint translocation with ulnar nerve entrapment: an unusual injury in a child
Authors: Najid Hamzah , Abdul Rashid Abdul Halim , Ibrahim Sharaf
Published: September 2018

Traumatic elbow dislocation in a child is rare, and it is usually associated with fractures. Simultaneous proximal radioulnar joint (PRUJ) translocation with ulnar nerve palsy is even rarer. We report an unusual case of a missed PRUJ translocation with ulnar nerve entrapment in a 10-year-old child. The key to diagnosing the translocation is the position of the proximal radius, which lies medial to the ulna. This was treated by open reduction and release of the entrapped nerve. The ulnar nerve palsy recovered fully at the 1-year follow-up. Although PRUJ translocation with ulnar nerve entrapment is a rare injury, a successful outcome is possible with timely open reduction and release of the ulnar nerve.
Are We Spending Wisely? Impact of POSNA Grants on Scholarly Productivity and Future Funding Success
Authors: Nhan Derek T. , Schoenecker Jonathan G. , Larson A. Noelle , Sponseller Paul D.
Published: September 2018

Background:

The Pediatric Orthopaedic Society of North America (POSNA) funds grants to improve pediatric musculoskeletal care and maximize new knowledge through publications, presentations, and further funding. We assessed the productivity of POSNA grants by number and rate of grant-specific publications, citations, and extramural funding; determined whether project type or completion status was associated with extramural funding; and compared the success of POSNA-funded versus all other podium presentations by publication rate and POSNA awards.

Methods:

We reviewed final reports for all 85 POSNA grants from 2003 to 2014. To determine grant productivity, we assessed the publication, presentation, and extramural funding rates, and the percentage of grants that achieved at least 1 scholarly output (publication or presentation). Citation counts were determined within 3 years after publication.

Results:

Overall, each grant achieved ~1.53 publications and 15.4 citations. Thirty-three percent secured extramural funding. However, 25% of grants could not be tracked to a scholarly product. Projects that reached completion and were of the basic science type (compared with clinical) were more likely to receive extramural funding. Compared with all other podiums, a greater proportion of POSNA-funded presentations led to a publication (64% vs. 48%, respectively; P=0.02) and were more likely to receive a POSNA award. Approximately 52% of funded projects were not presented at POSNA meetings.

Conclusions:

Although most POSNA-funded projects led to scholarly output, 25% of them produced no publications or podium presentations. POSNA-funded projects were more likely to lead to a publication and to have a higher chance of winning a POSNA award compared with all other projects. The POSNA grant process is effective at identifying impactful research, but continued process improvement, such as a prospectively maintained database of grant recipient productivity and improved tracking of grant submission histories, are both in development as the first steps to improve accountability of grant recipients in translating their projects to scholarly products.