Medical Student Parental Leave Policies at U.S. Medical Schools.

Background: As medical training occurs during prime childbearing years, parental leave policies may affect the career and family choices of medical students. Materials and Methods: This cross-sectional study builds on existing research by quantifying the prevalence of formal policies for parental leave in highly ranked United States Medical Degree granting institutions, and analyzing the characteristics of those policies, with the objective of identifying existing best practices for future policy adopters to consider. Results: Only 14% of the medical schools reviewed had substantive, stand-alone parental leave policies, and the majority of schools had leave of absence policies without mention of parental leave. Discussion: Leveraging the authors' legal and medical expertise, this analysis highlights existing best practices for medical school leadership to consider, as they examine and develop their policies. Best practices utilized by institutions with the most robust parental policies include adopting a formal and public parental policy, providing a parental enrolled academic adjustment option, guaranteeing approval to take and return from leave/academic adjustment, and continuing health care and financial aid benefits. Given the role of childbearing as a factor associated with gender disparities in academic medicine, and potential impact on racial disparities for students of color, medical school leadership should consider implementation of best practice parental policies to promote equity and wellness of their students. In fact, the deficit of robust parental leave policies in most highly ranked schools may contribute to existing gender and racial disparities in violation with antidiscrimination law. Strengthening policies could increase equity in medical education with positive impacts on the patient population.

Childbearing Among Women Cardiologists: The Interface of Experience, Impact, and the Law.

BACKGROUND: Maternity leave is highly variable in the United States given the lack of a federal workforce mandate. OBJECTIVES: The purpose of this study was to describe the experiences and impact of childbearing on women cardiologists and their careers, within a legal framework. METHODS: A survey was sent to women cardiologists, asking about their experiences while pregnant and on maternity leave. The incidence of complications and career impacts on the cardiologists was assessed. RESULTS: Of 323 respondents who had been pregnant as a practicing cardiologist, extra service or call before maternity leave was required in 37.2%. Of those who performed extra service or call, 17.5% were placed on bedrest before delivery, compared with 7.4% who did not perform extra service or call (P = 0.005). During the year of pregnancy, 41.2% experienced a salary decrease; only 7.4% had their relative value units prorated for time on maternity leave; 23.2% had no paid maternity leave. Self-reported pregnancy complications occurred in 36.5%, those with complications had a 60% greater chance of reporting that pregnancy adversely affected their career, compared with those without complications. Nearly three-fourths (237 respondents) reported experiencing at least one of several troubling practices that are illegal in many circumstances. CONCLUSIONS: Women cardiologists report wide variances in maternity leave in the United States, with many experiencing likely violations of the Family and Medical Leave Act or other statues. Childbearing issues in cardiologists should be addressed to improve the professional and personal lives of women cardiologists and the attractiveness of cardiology to potential trainees.

Is load control necessary to produce physiological AP displacement and axial rotation in wear testing of TAR?

The International Standard Organization, ISO 22622, specifies two options for joint wear simulator evaluation of total ankle replacements (TARs): load-controlled and displacement-controlled. In the present study, the load-controlled testing parameters were applied to cadaveric specimens to quantify and compare the observed sagittal translations and axial rotations to those specified under the displacement-controlled option. Twelve cadaveric specimens were stripped of extraneous tissues, keeping surrounding ankle ligaments. A halo was used to produce plantarflexion and dorsiflexion of the talus through two screws, while a baseplate resisted axial loads. The axial force and torque were applied to the tibia and fibula under force and torque feedback control. An anterior-posterior force was applied to the tibia. Plantarflexion-dorsiflexion were applied using rotation control. To protect the cadaveric specimens, loads were applied at 50% of the specified load profile while plantarflexion-dorsiflexion rotation was applied as specified. There was variation among specimens in magnitudes of anterior-posterior displacement with peaks ranging from 3.3 mm posteriorly to 3.0 mm anteriorly. Likewise, there was variation among specimens in magnitude of axial rotation, with peaks ranging from 11° external rotation to 4.5° internal rotation. However, the mean magnitudes of AP displacement and axial rotation did not exceed those specified by ISO 22622.

The Health Care Provider's Role in Securing Work Accommodations for Pregnant and Postpartum Patients.

Most women today are the primary, sole, or cobreadwinners for their families; their continued ability to work during and after pregnancy is crucial for their families' well-being. Midwives and other health care providers are regularly asked to provide work notes for patients who need adjustments to how, when, or where their job is done to continue working while maintaining a healthy pregnancy or breastfeeding. Whereas an improperly written work note can result in the patient being forced out on leave or losing their job, an effectively written work note from a health care provider can ensure the patient will receive the adjustments they need to stay safe and healthy on the job. Health care providers can also play an important role by incorporating discussions about workplace issues into care conversations. This article provides an overview of pregnancy-related employment rights, guidelines for writing effective work notes, and a discussion of common workplace issues patients face and how health care providers can respond.

Incidence and predictors of early complications following primary and revision total ankle arthroplasty.

BACKGROUND: Total ankle arthroplasty (TAA) offers an effective option for end-stage osteoarthritis. The incidence and preoperative risk factors for early adverse events (AEs) following primary and revision TAA may be useful information for providers. METHODS: A large database was queried from 2010 to 2016 to identify 905 patients of whom 818 underwent primary TAA (90.4%) and 87 underwent revision TAA (9.6%). Data on patient demographics, comorbidities, and hospital length of stay were analyzed as risk factors for reported 30-day AEs. RESULTS: The overall AE rate was 5.5% (50/905) for the entire cohort. AEs occurred more frequently for revision TAA (9/87) than primary TAA (41/818) cases (OR 2.43, p=0.022). Age (OR 1.03, p=0.045), BMI (OR 1.04, p=0.046), and revision TAA (OR 2.56, p=0.002) were independent risk factors for 30-day AEs in multivariate analysis. CONCLUSIONS: Older age, higher BMI, and revision cases are associated with a higher risk of AEs.

A Clinical Nurse's Walk Through Research: Relieving Postoperative Urinary Urgency.

A clinical nurse at a small community hospital recognized a need to help patients with urinary urgency following laparoscopic-assisted vaginal hysterectomy. The subsequent continuous quality improve- ment project is described.

Large BM Intra-Articular Allograft.

Posttraumatic tibiotalar arthritis is a challenging problem in young, active patients. Many of these patients do not want to pursue ankle arthrodesis after they fail conservative treatment measures, as they wish to preserve joint motion. Osteochondral shell allograft arthroplasty has been described as a reasonable alternative for treating these patients. The procedure itself is technically demanding; however, with improvements in surgical technique and adequate preoperative patient counseling, it provides improvement in ankle function and has good outcomes for most patients at long-term follow-up.

Incidence of Preoperative Deep Vein Thrombosis in Calcaneal Fractures.

OBJECTIVES: This study examined the incidence and risk factors of preoperative deep vein thrombosis (DVT) in patients presenting to an outpatient setting with an isolated calcaneal fracture. DESIGN: Retrospective chart review. SETTING: All patients included in the study presented to the treating surgeon at a Level I trauma center with isolated calcaneal fractures as an outpatient between 2005 and 2013. METHODS: These patients were either referred from outside hospitals, had been evaluated in the emergency department initially and presented for definitive care, or presented initially to the outpatient clinic. Patients included were over the age of 18, had a preoperative duplex ultrasonography of bilateral lower extremities per the treating surgeon's protocol, and had at minimum 6 weeks follow-up. Patients were excluded if they were a polytrauma, had a documented hypercoagulable state, or were on baseline pharmacologic anticoagulation for another condition. All patients had a preoperative duplex ultrasound of both lower extremities to evaluate for DVT at least 7 days after injury. MAIN OUTCOME MEASURE: Patients found to have a preoperative DVT were compared with those who did not have preoperative DVT for possible risk factors. RESULTS: One hundred fifty-nine patients qualified for our study and of these, 19 (12%) were found to have a DVT preoperatively, almost all of which were in distal veins. All risk factors, including age, sex, and body mass index were analyzed as continuous variables. Older age was found to be a risk factor for DVT (P = 0.009, Odds Ratio = 1.06, 95% CI, 1.01-1.11). All other predictor variables, including body mass index (P = 0.05) and sex (P = 0.08), were not statistically significant predictors in our sample. CONCLUSIONS: The incidence of preoperative DVT found here is almost 2 times as high as any previously published examination of lower extremity injuries. Physicians should be aware of this increase so they may counsel patients about the risks of DVTs and the likelihood of any sequelae from developing a DVT that may affect a patient's recovery. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Beyond Work-Life "Integration".

Research on the work-family interface began in the 1960s and has grown exponentially ever since. This vast amount of research, however, has had relatively little impact on workplace practice, and work-family conflict is at an all-time high. We review the work-family research to date and propose that a shift of attention is required, away from the individual experience of work and family and toward understanding how identity and status are defined at work. Several factors enshrine cherished identities around current workplace norms. The work devotion schema demands that those who are truly committed to their work will make it the central or sole focus of their lives, without family demands to distract them. Importantly, the work devotion schema underwrites valued class and gender identities: Work devotion is a key way of enacting elite class status and functions as the measure of a man--the longer the work hours and higher the demand for his attention, the better. Advocating change in the way work is done and life is lived meets resistance because it places these cherished identities at risk. Resistance to these identity threats keeps current workplace norms in place. This is why even the business case-which shows that current practices are not economically efficient-fails to persuade organizations to enact change. What is needed now is sustained attention to the implicit psychological infrastructure that cements the mismatch between today's workplace and today's workforce.

My Obstetrician Got Me Fired: How Work Notes Can Harm Pregnant Patients and What to Do About It.

Prenatal care providers are frequently asked to provide employment notes for their patients requesting medical leave or changes to work duties. Writing employment notes correctly can help patients negotiate for and obtain medically indicated workplace accommodations, allowing them to continue to work and earn an income. However, a poorly written or poorly timed note can jeopardize a patient's employment and salary. This commentary provides an overview of pregnancy-related employment laws and guidance in writing work accommodations letters that allow pregnant women to keep their jobs while maintaining a healthy pregnancy.

Intraoperative and perioperative complications during revision arthroplasty for salvage of a failed total ankle arthroplasty.

BACKGROUND: Revision of a failed total ankle arthroplasty (TAA) remains a challenge. Advances in total ankle implant design have renewed interest in revision TAA as an alternative to ankle arthrodesis or amputation in the management of a failed TAA. The purpose of our study was to review a series of failed Agility TAA revised to INBONE II TAA and identify reasons for revision as well as perioperative complications. METHODS: A retrospective review of 35 cases of failed Agility TAA revised to an INBONE II TAA was performed at 1 institution. Patient demographics, indications for revision, radiographs, and complications were reviewed. The average follow-up was 9.1 months (range, 0-28 months). All revisions were performed by 1 of 2 foot and ankle surgeons familiar with both prostheses. RESULTS: The Agility TAA lasted a mean of 6.7 years prior to revision to an INBONE II TAA. Revision TAA was indicated due to mechanical loosening, osteolysis, periprosthetic fracture, and a dislocated prosthesis. Adjunctive procedures were performed in 31 of 35 cases. There were 6 intraoperative and 5 acute postoperative complications, leading to an overall 31.4% complication rate. There was 1 patient with continued pain postoperatively who underwent a second revision of the INBONE II 20 months postoperatively. CONCLUSION: Revision TAA was a viable treatment option for failed TAA. A high risk of perioperative complications remains, and physicians should be aware of the challenges that occur during these procedures in order to plan for them preoperatively. LEVEL OF EVIDENCE: Level IV, retrospective case series.

A line drawn along the radial shaft misses the capitellum in 16% of radiographs of normal elbows.

BACKGROUND: The radiocapitellar line (RCL) is a routinely referenced radiographic measurement for evaluating injury of the pediatric elbow, such as a Monteggia fracture. It is most commonly described as a line drawn along the radius that should intercept the center of the capitellum in a normal elbow. However, the RCL has not been rigorously defined or validated in young children. METHODS: The RCL was drawn out on the anteroposterior and lateral radiographs of 116 normal pediatric elbows by 3 examiners. On each radiograph, lines were drawn along the longitudinal center of the radial neck as well as the radial shaft. The distance from each of these lines to the center of the capitellum was defined as the line-capitellar distance (LCD). The LCD was standardized to the patient size and correlated with patient variables. RESULTS: Of the 2052 RCLs drawn, 50% (1029/2052) fell outside the middle third of the capitellum and 8.6% (176/2052) missed the capitellum completely. Lines drawn along the radial neck in the anteroposterior and lateral views missed the capitellum less frequently (1.2% vs. 12.7%, P<0.0001) and passed through its central third less (77.8% vs. 44.7%, P<0.0001) when compared with lines drawn using the radial shaft. Lines along the radial neck intersected the capitellum significantly more often on the lateral view than on the anteroposterior view (98.8% vs. 96.8%, P=0.06) and were more likely to pass through the center third of the capitellum (77.8% vs. 55.5%, P<0.0001). With both techniques of drawing the RCL, the percent of measurements falling within the middle third of the capitellum was higher in patients above 5 years of age (P<0.001). The RCL is more reliable in older patients and shows considerable variation in infants. CONCLUSIONS: The RCL does not invariably bisect or fall within the middle third of the capitellum in normal pediatric elbows. Therefore, an abnormal RCL is suggestive but not pathognomonic for injury such as Monteggia fracture. An RCL drawn along the radial shaft will miss the capitellum in 15.6% of elbows. The most consistent RCL is drawn along the radial neck on the lateral view. Patient variables such as age and sex should be considered in the ability of the RCL to identify elbow injury. LEVEL OF EVIDENCE: Diagnostic Level 3.

West Nile virus infection in blood donors in the New York City area during the 2010 seasonal epidemic.

BACKGROUND: A uniform threshold strategy for converting from minipool (MP)-nucleic acid testing (NAT) to individual donation (ID)-NAT screening for acute West Nile virus (WNV) infection among blood donors is lacking. We report on WNV screening at the New York Blood Center during the 2010 seasonal WNV epidemic, the most severe epidemic in that state since the original outbreak in 1999. STUDY DESIGN AND METHODS: Between July 1 and October 31, 2010, blood donations were screened by MP-NAT or ID-NAT and the presence of anti-WNV immunoglobulin (Ig)M and IgG was evaluated among NAT-positive donations. RESULTS: Twenty presumed viremic donations were identified for a frequency of 0.0129% (1 in 7752 donations). Nine donations that could have been missed by MP-NAT were identified. Two of these donations were both IgM and IgG negative, one of which would have been missed if more than one positive donation was required for initiating ID-NAT. Retrospective ID-NAT revealed two positive donations. The majority of the NAT-positive donations in New York (16/19) were from donors who lived in counties that had the highest incidence of human WNV cases in the state. CONCLUSION: Our data details the identification of WNV NAT-positive blood donations during a severe seasonal epidemic in the New York area. By initiating ID-NAT after one positive donation, using retrospective testing, and triggering ID-NAT regionally, we were able to prevent the release of presumably infectious donations. The detection of NAT-positive donations with retrospective testing, however, may indicate the need for changes in our trigger criteria.

Neuroinvasive disease and West Nile virus infection, North Dakota, USA, 1999-2008.

To determine risk for West Nile virus (WNV) neuroinvasive disease in North Dakota, we tested plasma samples from blood donors for WNV IgG and compared infection rates with reported WNV neuroinvasive disease incidence. We estimate that 1 in 244 WNV infections leads to neuroinvasive disease; risk is substantially increased among men and older persons.

Acute HIV-1 infection is highly prevalent in Ugandan adults with suspected malaria.

OBJECTIVES: Acute febrile illnesses consistent with malaria are the most common presentation at health clinics in sub-Saharan Africa, accounting for 30-50% of outpatient visits. The symptoms of acute HIV infection can mimic acute malaria. We investigated whether acute HIV infections could be identified among adults with suspected malaria at rural health centers in Uganda. DESIGN: A cross-sectional study of 1000 consecutive patients referred for malaria blood smears at each of seven government health centers, of which 2893 (41%) were 13 years or older and tested for HIV. METHODS: HIV enzyme immunoassay antibody testing was performed on dried blood spots and confirmed by western blot. Enzyme immunoassay-nonreactive and enzyme immunoassay-reactive, western blot-unconfirmed samples were pooled (10/pool) and tested for HIV RNA by nucleic acid amplification testing. We defined acute HIV infection as HIV-1 RNA positive with a negative or indeterminate HIV-1 western blot pattern and early HIV infection as HIV-1 RNA positive with a positive western blot pattern, but with a BED-corrected optical density of below 0.8. RESULTS: Of 2893 patients evaluated, 324 (11%) had test results indicating HIV infection. Overall, 30 patients (1.0%) had acute HIV infection, 56 (1.8%) had early HIV infection, and 238 (8%) had established HIV infection. Acute HIV infections were more prevalent at sites with higher HIV prevalence and lower malaria endemicity. CONCLUSION: At multiple sites in Uganda, 1-3% of adults with suspected malaria had acute or early HIV infection. These findings highlight a major opportunity for expanding recognition of acute and early HIV infection in Africa.

West Nile virus testing experience in 2007: evaluation of different criteria for triggering individual-donation nucleic acid testing.

BACKGROUND: In 2007, clients served by Blood Systems Laboratories used variable approaches for triggering West Nile virus (WNV) RNA individual-donation (ID) nucleic acid testing (NAT). These included two minipool (MP) NAT-reactive donations and a greater than 1:1000 rate in a 7-day interval (primary trigger), criteria based on one MP-NAT-reactive donation when there was WNV activity in overlapping and/or adjacent geographic areas (neighbor trigger), or zero MP-NAT-reactive donation (self-trigger). STUDY DESIGN AND METHODS: The Procleix WNV assay was used in either a 16-sample MP or an ID format. NAT-repeat reactivity or anti-immunoglobulin M (IgM) positivity defined true positives (TPs). TPs that were negative on 1:16 dilution testing were considered ID-NAT yield cases. RESULTS: WNV NAT performed on 1,217,929 donations identified 162 TPs; 87 were detected by MP (rate of 0.008%) and 75 by ID (rate of 0.10%; p < 0.0001). There were 34 ID-NAT yield cases, including 4 IgM/immunoglobulin G (IgG)-negative and 9 IgM-positive/IgG-negative donations. Rates of yield cases by primary, neighbor, and self-triggering were 0.077, 0.052, and 0.004% (p = 0.0003). None of 11 ID-NAT yield cases detected by the neighbor trigger would have been detected if the primary trigger had been used. CONCLUSIONS: Primary triggering criteria identified 21 viremic donations that would have been missed by MP testing; however, 11 other low-level viremic donations required more stringent criteria (e.g., neighbor trigger) for detection. It is reasonable to adopt more stringent ID-NAT triggers, including elimination of the rate criterion and triggering on one NAT-reactive donation for regions adjacent to centers which have already triggered.

Evidence for persistent low-level viremia in individuals who control human immunodeficiency virus in the absence of antiretroviral therapy.

A subset of antiretroviral-untreated, human immunodeficiency virus (HIV)-infected individuals are able to maintain undetectable plasma HIV RNA levels in the absence of antiretroviral therapy. These "elite" controllers are of high interest as they may provide novel insights regarding host mechanisms of virus control. The degree to which these individuals have residual plasma viremia has not been well defined. We performed a longitudinal study of 46 elite controllers, defined as HIV-seropositive, antiretroviral-untreated individuals with plasma HIV RNA levels of <50 to 75 copies/ml. The median duration of HIV diagnosis was 13 years, the median baseline CD4(+) T-cell count was 753 cells/mm(3), and the median duration of follow-up was 16 months. Plasma and cellular HIV RNA levels were measured using the transcription-mediated amplification (TMA) assay (estimated limit of detection of <3.5 copies RNA/ml). A total of 1,117 TMA assays were performed (median of five time points/subject and four replicates/time point). All but one subject had detectable plasma HIV RNA on at least one time point, and 15 (33%) subjects had detectable RNA at all time points. The majority of controllers also had detectable cell-associated RNA and proviral DNA. A mixed-effect linear model showed no strong evidence of change in plasma RNA levels over time. In conclusion, the vast majority (98%) of elite controllers had measurable plasma HIV RNA, often at levels higher than that observed in antiretroviral-treated patients. This confirms the failure to eradicate the virus, even in these unique individuals who are able to reduce plasma viremia to very low levels without antiretroviral therapy.