Enhancing practice efficiency: A key organizational strategy to improve professional fulfillment in allergy and immunology.

OBJECTIVE: To review evidence-based strategies that have been noted to improve professional fulfillment and reduce burnout by enhancing practice efficiency. DATA SOURCES: A comprehensive literature review was conducted to evaluate the strategies to improve efficiency of practice-a key driver of burnout among physicians. STUDY SELECTIONS: Studies of efficiency-enhancing practices relevant to allergy-immunology were included. RESULTS: Professional burnout is prevalent among physicians and is associated with negative outcomes affecting physicians, patients, and health care organizations. Recent surveys suggest at least 35% of US allergists-immunologists experience burnout. There are multiple drivers of professional burnout, some at the individual level and others at the organizational or practice level. Strategies to improve professional fulfillment may be conceptualized using the Stanford physician wellness framework, in which efforts target the following 3 reciprocal domains: culture, personal resilience, and practice efficiency. Organizational strategies that support physician well-being by creating a more efficient practice environment hold great promise, particularly for allergists-immunologists. The reduction of administrative burden and fostering of team-based care have been found in multiple studies to be cost-effective strategies to improve physician and patient satisfaction. CONCLUSION: To ensure the well-being of the US allergy-immunology workforce and optimize patient outcomes, both private and academic allergy-immunology institutions should prioritize the adoption and iterative evaluation and refinement of these strategies to cocreate an efficient and ideal practice environment.

Fine Wire Circular Fixation for Displaced Intra-Articular Calcaneal Fractures: A Systematic Review.

Intra-articular calcaneal fractures represent an ongoing challenge for the orthopedic community, with the benefits of the previous "gold standard" treatment of open reduction and internal fixation having been called into question in several large randomized controlled trials. Fine wire circular fixation may represent a useful alternative treatment for these injuries, combining minimally invasive application with rigid fixation, which allows the possibility of early weight bearing We performed a systematic review of published studies that used circular fixation for calcaneal fractures and recorded functional outcomes at follow-up. In a total of 11 studies with 255 calcaneal fractures for which there was follow-up, our inclusion criteria were met: 8.2% of fractures were bilateral, 11.9% of fractures were open fractures, and 12.6% of patients had multiple orthopedic injuries. Functional outcomes were assessed with the use of a variety of tools across the different studies, but outcomes compared favorably with those seen with open reduction and internal fixation. Although pin site infections were common (22.6%), serious complications, including deep infection (0.8%), wound infection (1.6%), and complex regional pain syndrome (0.8%), were exceedingly rare. The results suggest that this is a viable alternative treatment for calcaneal fractures, but higher-quality randomized controlled trials are required before the technique can enter mainstream use.

Single versus two-stage management of long-bone chronic osteomyelitis in adults: a systematic review and meta-analysis.

BACKGROUND: Chronic osteomyelitis is a debilitating bone infection, characterized by a persistent infection over months to years, poses diagnostic and therapeutic challenges due to its insidious nature and potential for severe bone and soft tissue destruction. This systematic review and meta-analysis aims to review the literature on the treatment of chronic osteomyelitis in long bones and assess cure rates in single versus two-stage surgery. METHODS: Following the PRISMA guidelines and registered with PROSPERO (ID: CRD42021231237), this review included studies that reported on the management of chronic osteomyelitis in long bones using either a planned one-stage or two-stage surgical approach in adult patients. Databases searched included Medline, Embase, Web of Science, CINAHL, HMIC, and AMED, using keywords related to osteomyelitis, long bones, and surgical management. Eligibility criteria focused on adults with chronic osteomyelitis in long bones, with outcomes reported after a minimum follow-up of 12 months. The meta-analysis utilized the random-effects model to pool cure rates. RESULTS: The analysis included 42 studies with a total of 1605 patients. The overall pooled cure rate was 91% (CI 95%) with no significant difference observed between single-stage and two-stage surgeries (X2 = 0.76, P > 0.05). Complications were reported in 26.6% of cases in single-stage procedures and 27.6% in two-stage procedures, with prolonged wound drainage noted as a common issue. Dead space management techniques varied across studies, with antibiotic-loaded calcium sulphate beads used in 30.4% of cases. CONCLUSION: This meta-analysis reveals no significant difference in cure rates between single and two-stage surgical treatments for chronic osteomyelitis in long bones, supporting the efficacy of both approaches. The current treatment strategy should include a combination of debridement, dead space management using local and systematic antibiotics and soft tissue reconstruction if necessary.

Clinician Wellness During the COVID-19 Pandemic: Extraordinary Times and Unusual Challenges for the Allergist/Immunologist.

The global spread of coronavirus disease 2019 (COVID-19) has caused sudden and dramatic societal changes. The allergy/immunology community has quickly responded by mobilizing practice adjustments and embracing new paradigms of care to protect patients and staff from severe acute respiratory syndrome coronavirus 2 exposure. Social distancing is key to slowing contagion but adds to complexity of care and increases isolation and anxiety. Uncertainty exists across a new COVID-19 reality, and clinician well-being may be an underappreciated priority. Wellness incorporates mental, physical, and spiritual health to protect against burnout, which impairs both coping and caregiving abilities. Understanding the stressors that COVID-19 is placing on clinicians can assist in recognizing what is needed to return to a point of wellness. Clinicians can leverage easily accessible tools, including the Strength-Focused and Meaning-Oriented Approach to Resilience and Transformation approach, wellness apps, mindfulness, and gratitude. Realizing early warning signs of anxiety, depression, substance abuse, and posttraumatic stress disorder is important to access safe and confidential resources. Implementing wellness strategies can improve flexibility, resilience, and outlook. Historical parallels demonstrate that perseverance is as inevitable as pandemics and that we need not navigate this unprecedented time alone.

Percutaneous Antegrade Colonic Stent Insertion Using a Proximal Trans-peritoneal Colopexy Technique.

INTRODUCTION: Conventionally, colonic stents are inserted with a retrograde trans-anal approach-however, stenting of right-sided or proximal transverse colon lesions may pose a challenge due to tortuosity or long distances. We report three successful cases of percutaneous antegrade colonic stenting in patients using a proximal trans-peritoneal colopexy technique. MATERIALS AND METHODS: Three patients underwent a proximal trans-peritoneal colopexy technique for antegrade colonic stent placement. The patients included three males, ages 89, 92 and 55, who were unsuitable for conventional methods. All patients had a colopexy with the aid of three gastropexy sutures performed under CT or fluoroscopic guidance and subsequent colonic access, followed by the crossing lesion and subsequent deployment of an uncovered colonic stent. A 10-Fr pigtail catheter was exchanged for the sheath, capped and left in place along with the colopexy suture anchors. RESULTS: Percutaneous antegrade colonic stent placement was technically successful in all patients with no complications. Follow-up at 10 days, a tubogram confirmed stent patency. The pigtail drain and suture anchors were subsequently removed. CONCLUSION: Antegrade colonic stenting with the use of a three point colopexy is a straightforward well-tolerated procedure and is a useful technique in a cohort of patients in whom conventional stenting has failed/is unsuitable. Additionally, we believe we have reported the first two cases involving transverse colon access for stenting.

Rectus sheath haematoma: a rare presentation of non-contact strenuous exercises.

Rectus sheath haematoma (RSH) is a well-documented but uncommon clinical condition. It is usually a self-limiting condition but can present as a life-threatening emergency. RSH after non-contact vigorous exercise is unknown. Two such cases secondary to yoga and laughter therapy sessions, respectively, are reported. One of them required surgical intervention, whereas the other was successfully treated conservatively.

Anaphylaxis and urticaria.

Anaphylaxis and urticaria are common presenting allergic complaints. Affecting up to 2% of the population, anaphylaxis is a serious, life-threatening allergic reaction. Although not life-threatening, urticaria is a rash of transient, erythematous, pruritic wheals that can be bothersome and affects up to 25% of the population. All cases of anaphylaxis warrant thorough clinical evaluation by the allergist-immunologist, although most cases of urticaria are self-limited and do not require specialist referral. This article offers an overview of our current knowledge on the epidemiology, pathogenesis, triggers, diagnosis, and treatment of anaphylaxis and urticaria.