Local recurrence rates of superficial versus deep soft tissue sarcoma.

INTRODUCTION: Soft tissue sarcomas are a group of malignancies that commonly occur in the extremities. As deep lesions may exist within the confines of the muscular fascia, we postulate that local recurrence rates are higher for superficial soft tissue sarcomas managed by the standard of care. MATERIALS AND METHODS: A retrospective review was performed on 90 patients who underwent surgical resection of soft tissue sarcomas of the extremity from 2007 to 2015. Patients with minimum 2-year follow-up and adequate operative, pathologic, and clinical outcomes data were included. RESULTS: Mean age was 54 ± 18 years with 49 (54.4%) patients being male. Lesions in 77.8% of cases were deep, and 22.2% were superficial to fascia. Following the index surgical resection, a total of 33 (36.7%) patients had positive margins. A total of 17 (18.9%) patients had a local recurrence. Overall, 3-year survival was 92.7%, and 5-year survival was 79.0%. Five-year recurrence-free survival of deep sarcomas was 91.1% versus 58.2% of superficial lesions (p = 0.006). Patients with higher tumor depth had lower odds of experiencing a local recurrence (HR 0.26 [95% CI 0.09-0.72]). Local recurence rates was also associated with positive surgical margins on initial resection (33.3% versus 12.3%) (p = 0.027). CONCLUSIONS: In this series, superficial tumor depth was associated with local recurrence of soft tissue sarcomas of the extremity following surgical resection. Positive surgical margins was also associated with local recurrence.

Soil organic carbon, aggregation and fungi community after 44 years of no-till and cropping systems in the Central Great Plains, USA.

Implementing sustainable agricultural land management practices such as no-till (NT) and diversified crops are important for maintaining soil health properties. This study focuses on the soil health of three long-term (44 years) tillage systems, NT, reduced tillage (RT), and conventional tillage (CT), in monoculture winter wheat-fallow (W-F) (Triticum aestivum L.) and wheat-soybean (W-S) (Glycine max (L.) Merrill) rotation. Soil organic carbon (C) was higher in NT than CT in the surface 0-5 cm, but not different in the 5-15 cm, demonstrating SOC stratification on the soil profile. The soil water content was higher in NT followed by RT and CT in the top 0-5 cm. We found an association between increased carbon, aggregation, and AMF biomass. Greater soil aggregation, carbon and AMF were observed in NT at 0-5 cm soil depth. The W-S cropping system had greater soil microbial community composition based on fungi biomass, AMF and fungal to bacteria ratio from phospholipid fatty acid analysis (PLFA). Large macroaggregates were positively correlated with total C and N, microbial biomass, Gram + , and AMF. Soil water content was positively correlated with macroaggregates, total C and N, and AC. No-till increased soil carbon content even after 44 years of cultivation. By implementing conservation tillage systems and diversified crop rotation, soil quality can be improved through greater soil organic C, water content, greater soil structure, and higher AMF biomass than CT practice in the Central Great Plains.

Outcomes of Pediatric Scaphoid Nonunions Treated With Distal Radius Cancellous Autograft.

BACKGROUND: The optimal management of pediatric scaphoid fracture nonunions is controversial. We hypothesize that pediatric patients with scaphoid fracture nonunions will have favorable functional outcomes with the utilization of nonvascularized distal radius cancellous autograft with open reduction and internal fixation (ORIF). METHODS: A review was performed from 2012 to 2017 identifying skeletally immature patients with scaphoid fracture nonunions treated with ORIF and nonvascularized distal radius cancellous autograft, including demographic data, mechanism of injury, length of time from injury to treatment, operative procedure, length of immobilization, time to union, and complications. RESULTS: Ten patients (9 males, 1 female) met inclusion criteria. Mean age was 14.3 SD 1.5 years. The majority of fractures were sustained during sports or secondary to a fall. Mean time between injury and orthopaedic evaluation was 33 weeks (SD 20 wk). Eight fractures occurred at the waist, and 2 occurred at the proximal pole. Four patients had a humpback deformity, and three presented with a dorsal intercalated segmental instability deformity. Nine patients were treated with a single cannulated compression screw with distal radius autograft. One patient also received a single Kirschner wire fixation in addition to a single cannulated screw and graft. Patients underwent a mean postoperative immobilization period of 14 SD 5 weeks. Two patients received a bone stimulator postoperatively. Radiographic union was documented after initial surgery in nine patients, with mean time to union of 17 SD 5 weeks. The 1 patient with persistent radiographic nonunion underwent revision fixation and repeat nonvascularized distal radius autograft, achieving union and resolution of symptoms. All patients ultimately reported full return to activity. CONCLUSIONS: Pediatric scaphoid fracture nonunions that undergo ORIF using nonvascularized distal radius cancellous autograft have favorable rates of consolidation and functional outcomes. Surgeons should consider this source of grafting in operative management of scaphoid nonunions in children and adolescents. LEVEL OF EVIDENCE: Level IV, therapeutic.

How Does Representation of Women on Editorial Boards Compare Among Orthopaedic, General Surgery, and Internal Medicine Journals?

BACKGROUND: Women have historically been underrepresented as editors of peer-reviewed medical journals. Studies have demonstrated that there are differences in editorial board reviewer behavior based on gender, suggesting that greater representation by women on editorial boards may improve the quality and diversity of the review process. Therefore, the current representation of women on the editorial boards of orthopaedic journals, particularly compared with peer-reviewed surgical and medical journals, is of interest. QUESTIONS/PURPOSES: (1) What is the representation of women as members of editorial boards of prominent orthopaedic surgery journals? (2) How does it compare with representation on the editorial boards of journals in general surgery and internal medicine? METHODS: The top 15 journals with a strong clinical emphasis based on Impact Factor (Clarivate Analytics) calculated by the 2018 Journal Citation Reports were identified for orthopaedic surgery, general surgery (and all general surgical subspecialties), and internal medicine (with representative internal medicine subspecialties). Clinical publications with their primary editorial office located in the United States led predominantly by physicians or basic scientists were eligible for inclusion. The members of an editorial board were identified from the journals' websites. The gender of editors with gender-neutral names (and editors whose gender we considered uncertain) was identified by an internet search for gender-specific pronouns and/or pictures from an institutional profile. Fisher exact tests and t-tests were used to analyze categorical and continuous variables, respectively. Significance was set at p < 0.05. RESULTS: Of the editors analyzed, women made up 9% (121 of 1383) of editorial boards in the orthopaedic journals with the highest Impact Factors, compared with 21% (342 of 1665) of general surgery journals (p < 0.001) and 35% (204 of 587) of internal medicine journals (p < 0.001). The overall mean composition of editorial boards of orthopaedic journals was 10% ± 8% women, compared with that of general surgery, which was 19% ± 6% women (p < 0.001), and that of internal medicine, which was 40% ± 19% women (p < 0.001). CONCLUSION: Women make up a smaller proportion of editorial boards at orthopaedic surgery journals than they do at general surgery and internal medicine journals. However, their representation appears to be comparable to the proportion of women in orthopaedics overall (approximately 6%) and the proportion of women in academic orthopaedics (approximately 19%). Ways to improve the proportion of women on editorial boards might include structured mentorship programs at institutions and personal responsibility for championing mentorship and diversity on an individual level. CLINICAL RELEVANCE: Increasing representation of women on editorial boards may improve the diversity of perspectives and quality of future published research, generate visible role models for young women considering orthopaedics as a career, and improve patient care through enriching the diversity of our specialty.

Pediatric Medial Epicondyle Fracture Management: A Systematic Review.

BACKGROUND: There remains controversy surrounding the treatment of pediatric medial epicondyle fractures. This systematic review examines the existing literature with the aim to elucidate optimal management strategies. METHODS: A systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was executed. All data collection was completed by August 01, 2018. Functional outcomes, diagnostic imaging, athlete management, union rates, ulnar nerve symptoms, surgical methods, surgical positioning, and posttreatment protocols were categorized and recorded. Frequency-weighted mean values were calculated with associated SDs. RESULTS: Thirty-seven studies with 1022 patients met the inclusion criteria. Functional outcomes for patients were mostly good following operative and nonoperative management. The most common complication was a slight loss of elbow extension (7.6±5.9 degrees) and flexion (13.3±5.8 degrees). Operative treatment was associated with higher union rates than nonoperative management (700/725, 96% vs. 69/250, 28%; P<0.001). Standard diagnostic imaging techniques to measure displacement were unreliable with a newly proposed axial view having high inter-rater and intrarater reliability. The most common surgical method used was open reduction and internal fixation with Kirschner wires. Whereas surgical management of patients with associated ulnar nerve symptoms led to symptom resolution, nonoperative management occasionally led to the development of these symptoms. Elbow range of motion was initiated at ~2.8±1.4 (range, 0 to 8 wk) weeks after surgery and 3.4±1.2 (range, 3 to 5 wk) weeks without surgery (P<0.001). CONCLUSIONS: Although there is still no consensus on treatment of pediatric medial epicondyle fractures, both operative and nonoperative approaches result in good outcomes. LEVEL OF EVIDENCE: Level IV-therapeutic.

Validation of the Pediatric Appendicitis Risk Calculator (pARC) in a Community Emergency Department Setting.

STUDY OBJECTIVE: The pediatric Appendicitis Risk Calculator (pARC) is a validated clinical tool for assessing a child's probability of appendicitis. Our objective was to assess the performance of the pARC in community emergency departments (EDs) and to compare its performance with that of the Pediatric Appendicitis Score (PAS). METHODS: We conducted a prospective validation study from October 1, 2016, to April 30, 2018, in 11 community EDs serving general populations. Patients aged 5 to 20.9 years and with a chief complaint of abdominal pain and less than or equal to 5 days of right-sided or diffuse abdominal pain were eligible for study enrollment. Our primary outcome was the presence or absence of appendicitis within 7 days of the index visit. We reported performance characteristics and secondary outcomes by pARC risk strata and compared the receiver operator characteristic (ROC) curves of the PAS and pARC. RESULTS: We enrolled 2,089 patients with a mean age of 12.4 years, 46% of whom were male patients. Appendicitis was confirmed in 353 patients (16.9%), of whom 55 (15.6%) had perforated appendixes. Fifty-four percent of patients had very low (<5%) or low (5% to 14%) predicted risk, 43% had intermediate risk (15% to 84%), and 4% had high risk (≥85%). In the very-low- and low-risk groups, 1.4% and 3.0% of patients had appendicitis, respectively. The area under the ROC curve was 0.89 (95% confidence interval 0.87 to 0.92) for the pARC compared with 0.80 (95% confidence interval 0.77 to 0.82) for the PAS. CONCLUSION: The pARC accurately assessed appendicitis risk for children aged 5 years and older in community EDs and the pARC outperformed the PAS.

Increasing Safe Outpatient Management of Emergency Department Patients With Pulmonary Embolism: A Controlled Pragmatic Trial.

Background: Many low-risk patients with acute pulmonary embolism (PE) in the emergency department (ED) are eligible for outpatient care but are hospitalized nonetheless. One impediment to home discharge is the difficulty of identifying which patients can safely forgo hospitalization. Objective: To evaluate the effect of an integrated electronic clinical decision support system (CDSS) to facilitate risk stratification and decision making at the site of care for patients with acute PE. Design: Controlled pragmatic trial. (ClinicalTrials.gov: NCT03601676). Setting: All 21 community EDs of an integrated health care delivery system (Kaiser Permanente Northern California). Patients: Adult ED patients with acute PE. Intervention: Ten intervention sites selected by convenience received a multidimensional technology and education intervention at month 9 of a 16-month study period (January 2014 to April 2015); the remaining 11 sites served as concurrent controls. Measurements: The primary outcome was discharge to home from either the ED or a short-term (<24-hour) outpatient observation unit based in the ED. Adverse outcomes included return visits for PE-related symptoms within 5 days and recurrent venous thromboembolism, major hemorrhage, and all-cause mortality within 30 days. A difference-in-differences approach was used to compare pre-post changes at intervention versus control sites, with adjustment for demographic and clinical characteristics. Results: Among 881 eligible patients diagnosed with PE at intervention sites and 822 at control sites, adjusted home discharge increased at intervention sites (17.4% pre- to 28.0% postintervention) without a concurrent increase at control sites (15.1% pre- and 14.5% postintervention). The difference-in-differences comparison was 11.3 percentage points (95% CI, 3.0 to 19.5 percentage points; P = 0.007). No increases were seen in 5-day return visits related to PE or in 30-day major adverse outcomes associated with CDSS implementation. Limitation: Lack of random allocation. Conclusion: Implementation and structured promotion of a CDSS to aid physicians in site-of-care decision making for ED patients with acute PE safely increased outpatient management. Primary Funding Source: Garfield Memorial National Research Fund and The Permanente Medical Group Delivery Science and Physician Researcher Programs.

Reduction of Opioid Use After Upper-Extremity Surgery through a Predictive Pain Calculator and Comprehensive Pain Plan.

PURPOSE: For outpatient hand and upper-extremity surgeries, opioid prescriptions may exceed the actual need for adequate pain control. The purposes of this study were to (1) determine rates of opioid wasting and consumption after these procedures and (2) create and implement a patient-specific calculator for opioid requirements with a detailed multimodal analgesic plan to guide postoperative prescriptions. METHODS: Patients undergoing hand and upper-extremity surgery at a single ambulatory surgery center were recruited before (n = 305) and after (n = 221) implementation of a postoperative pain control program. On the first postoperative visit, patients were given a questionnaire regarding opioid use and pain control satisfaction. Demographic and procedural data were collected via chart review. With these data from the first cohort, we developed a patient-specific opioid calculator and pain plan that was implemented for the second cohort of patients. Bivariate analysis and multivariable regression analysis were used to determine the effect of the intervention. RESULTS: Pre-intervention data suggested that younger age; baseline opioid use; use of regional block; unemployment; procedures involving bony, tendinous, or ligamentous work (as opposed to soft tissue alone); and longer procedure time were predictive of higher opioid consumption. Pre- and post-intervention cohorts had similar age and sex distributions as well as procedure length. After the intervention, opioids prescribed decreased 63% from a mean of 32.0 ± 15.0 pills/surgery or 194.5 ± 120.2 morphine milligram equivalents (MMEs) to 11.7 ± 8.9 pills/surgery or 86.4 ± 67.2 MMEs. Opioid consumption decreased 58% from a mean of 21.7 ± 25.0 pills/surgery (137.7 ± 176.4 MMEs) to 9.3 ± 16.7 (64.4 ± 113.4 MMEs). Opioid wastage decreased 62% from 13.8 ± 13.5 pills/surgery (62.8 ± 138.0 MMEs) to 5.2 ± 10.3 (24.8 ± 89.9 MMEs). Implementation of the pain plan and calculator did not affect the odds of unsatisfactory patient-rated pain control or unplanned opioid refills. CONCLUSIONS: With implementation of a comprehensive pain plan for ambulatory upper-extremity surgery, it is possible to reduce opioid prescription, consumption, and wastage rates without compromising patient satisfaction with pain control or increasing rates of unplanned pain medication refills. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Treatment of Acute Seymour Fractures.

BACKGROUND: Seymour fractures are distal phalanx fractures in children with a juxta-epiphyseal pattern. The purpose of our study was to investigate the treatments, outcomes, operative ;indications, and antibiotic choice for acute Seymour fractures (presenting within 24 h of injury), to better define optimal management. We hypothesized that: (1) cephalexin provides adequate antibiotic coverage for acute Seymour fractures; (2) most injuries will achieve good outcomes with management in the emergency department (ED) alone; and (3) indication for operative intervention is unsuccessful or unstable reduction in the ED. METHODS: We performed a retrospective study of patients under 18 years old treated at a large pediatric hospital from 2009 to 2017 for an acute Seymour fracture. Study outcomes included management and antibiotic type, infection, fracture healing, malunion, physeal disturbance, nail dystrophy, antibiotic failure, and need for unplanned operative intervention. RESULTS: Mean age of patients was 10 years, with 43 males and 22 females sustaining 65 Seymour fractures. Fifty-eight cases (89%) were initially managed in the emergency department. Seven cases were initially managed with an operative intervention that included I&D, open reduction, and K-wire fixation. The most commonly cited surgical indication was unsuccessful closed reduction. Four patients initially managed in the ED required an unplanned operation, usually because of fracture redisplacement. Complications were rare, with superficial infections being most common. CONCLUSIONS: Most acute Seymour fractures can be successfully managed in the emergency department if stable reduction is achieved. LEVEL OF EVIDENCE: Level IV, therapeutic.

Outpatient Management of Emergency Department Patients With Acute Pulmonary Embolism: Variation, Patient Characteristics, and Outcomes.

STUDY OBJECTIVE: Outpatient management of emergency department (ED) patients with acute pulmonary embolism is uncommon. We seek to evaluate the facility-level variation of outpatient pulmonary embolism management and to describe patient characteristics and outcomes associated with home discharge. METHODS: The Management of Acute Pulmonary Embolism (MAPLE) study is a retrospective cohort study of patients with acute pulmonary embolism undertaken in 21 community EDs from January 2013 to April 2015. We gathered demographic and clinical variables from comprehensive electronic health records and structured manual chart review. We used multivariable logistic regression to assess the association between patient characteristics and home discharge. We report ED length of stay, consultations, 5-day pulmonary embolism-related return visits and 30-day major hemorrhage, recurrent venous thromboembolism, and all-cause mortality. RESULTS: Of 2,387 patients, 179 were discharged home (7.5%). Home discharge varied significantly between EDs, from 0% to 14.3% (median 7.0%; interquartile range 4.2% to 10.9%). Median length of stay for home discharge patients (excluding those who arrived with a new pulmonary embolism diagnosis) was 6.0 hours (interquartile range 4.6 to 7.2 hours) and 81% received consultations. On adjusted analysis, ambulance arrival, abnormal vital signs, syncope or presyncope, deep venous thrombosis, elevated cardiac biomarker levels, and more proximal emboli were inversely associated with home discharge. Thirteen patients (7.2%) who were discharged home had a 5-day pulmonary embolism-related return visit. Thirty-day major hemorrhage and recurrent venous thromboembolism were uncommon and similar between patients hospitalized and those discharged home. All-cause 30-day mortality was lower in the home discharge group (1.1% versus 4.4%). CONCLUSION: Home discharge of ED patients with acute pulmonary embolism was uncommon and varied significantly between facilities. Patients selected for outpatient management had a low incidence of adverse outcomes.

Surgical and Nonsurgical Management of Mallet Finger: A Systematic Review.

PURPOSE: The current literature describes multiple surgical and nonsurgical techniques for the management of mallet finger injuries, and there is no consensus on the indications for surgical treatment. The objective of this study was to determine, through a literature review, if any conclusions can be drawn concerning the indications for surgery in mallet finger injuries; the treatment outcomes of surgical versus nonsurgical management; the most effective methods of surgical and nonsurgical treatment; and the most common treatment complications of mallet finger injuries. METHODS: A systematic review of multiple databases was performed. English language clinical studies evaluating therapeutic interventions for mallet fingers that reported objective, standardized outcome measures were included. Basic science studies, cadaveric studies, conference abstracts, level V evidence studies, studies lacking statistical data, and tendinous injuries other than mallet fingers were excluded. Salvage procedures and studies evaluating exclusively chronic lesions were also excluded. RESULTS: Forty-four studies that reported clinical outcomes for the treatment of mallet finger injuries, 22 evaluating surgical treatments and 17 studies investigating nonsurgical treatments were included. The average distal interphalangeal joint extensor lag was 5.7° after surgical treatment and 7.6° after nonsurgical treatment. Complication rates of surgical and nonsurgical interventions were comparable (14.5% and 12.8%, respectively). Five studies directly compared the outcomes of surgical with nonsurgical management, with mixed results and recommendations. CONCLUSIONS: Both surgical and nonsurgical treatments of mallet finger injuries lead to excellent clinical outcomes. Insufficient evidence is available to determine when surgical intervention is indicated. Based on our literature review, it appears that these treatments are equivalent and should be individualized to the patient. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Outcomes of Splinting in Pediatric Mallet Finger.

PURPOSE: Excessive flexion at the distal interphalangeal (DIP) joint disrupts the extensor mechanism, leading to mallet finger injuries. The goal of management is to restore active DIP joint extension. We sought to learn which variables (treatment technique, injury type, time to presentation, adherence to treatment) affect clinical outcomes of pediatric mallet finger injuries. METHODS: A retrospective review was performed of patients who presented with mallet finger injuries during 2013 to 2017 at a large pediatric hospital. Patient characteristics, treatments, outcomes, and radiographic data were collected. Types of nonsurgical treatment, acute versus delayed (> 28 days) presentation, and compliant versus noncompliant patients were compared. Differences in extension lag and incidence of complications were evaluated. RESULTS: There were 94 patients with 99 mallet fingers, with a mean age of 13.7 years, 66 of whom were boys (70%) and 28 girls (30%). Most injuries occurred during recreation (78%). Ninety-nine percent of patients were treated nonsurgically with extension orthoses. The majority of injuries were bony mallets (80%). The outcomes resulted in a mean extension lag of 1°. Of patients presenting acutely, residual extension lag and complications occurred in 12% and 9%, respectively; the lag and complication rate for patients presenting after a delay was 25% and 19%, respectively. Treatment adherence was associated with better clinical outcomes, with nonadherent patients more likely to experience a residual extensor lag (11% vs 67%) and potentially clinically relevant complications (8% vs 50%). CONCLUSIONS: The majority of pediatric mallet finger injuries can achieve good outcomes with nonsurgical treatment. Absolute indications for surgery in this population remain unclear. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

When is hemiarthroplasty preferable to intramedullary prophylactic fixation of malignant lesions of the proximal femur?

BACKGROUND: Malignant hip lesions can be managed operatively by intramedullary (IM) nail fixation and hemiarthroplasty. METHODS: A retrospective review was performed on 86 patients who underwent hemiarthroplasty (n = 22) or IM nail fixation (n = 64) for prophylactic treatment of impending pathologic fracture due to malignant lesions of the hip. Cox proportional hazards and logistic regression modeling were performed to determine risk of death, fixation failure, pain relief, and return to ambulation without gait aids. RESULTS: Median survival time after surgery was 8.8 months (with no difference in survival between hemiarthroplasty and IM nail [adjusted Hazard Ratio 1.40, CI 0.72, 2.53; P = 0.31]). Hemiarthroplasty was associated with lower risk of pathologic fracture, fixation failure, or reoperation (adjusted HR 0.02, CI < 0.001, 0.48; P = 0.01). Hemiarthroplasty did not increase odds of unassisted ambulation compared to IM nail fixation (adjusted Odds Ratio [OR] 2.23, CI 0.56, 9.71; P = 0.26). The strongest predictor of postoperative ambulation was preoperative ambulation without aids (adjusted OR 28.9, CI 7.37, 161; P < 0.001). CONCLUSIONS: There is no difference in survival or likelihood of unassisted ambulation after prophylactic femoral fixation with IM nails versus hemiarthroplasty in patients with metastatic disease of proximal femur.

Feasibility of a Low-Cost, Interactive Gaming System to Assess Balance in Older Women.

The use of low-cost interactive game technology for balance rehabilitation has become more popular recently, with generally good outcomes. Very little research has been undertaken to determine whether this technology is appropriate for balance assessment. The Wii balance board has good reliability and is comparable to a research-grade force plate; however, recent studies examining the relationship between Wii Fit games and measures of balance and mobility demonstrate conflicting findings. This study found that the Wii Fit was feasible for community-dwelling older women to safely use the balance board and quickly learn the Wii Fit games. The Ski Slalom game scores were strongly correlated with several balance and mobility measures, whereas Table Tilt game scores were not. Based on these findings, the Ski Slalom game may have utility in the evaluation of balance problems in community-dwelling older adults.

Interspecialty Variation in Perioperative Health Care Resource Usage for Carpal Tunnel Release.

BACKGROUND: We investigated whether any interspecialty variation exists, regarding perioperative health care resource usage, in carpal tunnel releases (CTRs). METHODS: The 2010 to 2021 PearlDiver Mariner Database, an all-payer claims database, was queried to identify patients undergoing primary CTRs. Physician specialty IDs were used to identify the specialty of the surgeon-orthopedic versus plastic versus general surgery versus neurosurgery. Multivariate logistic regression analysis was used to identify whether there was any interspecialty variation between the use of health care resources. RESULTS: A total of 908 671 patients undergoing CTRs were included, of which 556 339 (61.2%) were by orthopedic surgeons, 297 047 (32.7%) by plastic surgeons, 44 118 (4.9%) by neurosurgeons, and 11 257 (1.2%) by general surgeons. In comparison with orthopedic surgeons, patients treated by plastic surgeons were less likely to have received opioids, nonsteroidal anti-inflammatory drugs, oral steroids, and preoperative antibiotic prophylaxis but were more likely to have received steroid injections and electrodiagnostic studies (EDSs) preoperatively. Patients treated by neurosurgeons were more likely to have received preoperative opioids, gabapentin, oral steroids, preoperative antibiotic prophylaxis, EDSs, and formal preoperative physical/occupational therapy and less likely to have received steroid injections. Patients treated by general surgeons were less likely to receive oral steroids, steroid injections, EDSs, preoperative formal physical therapy, and preoperative antibiotic prophylaxis, but were more likely to be prescribed gabapentin. CONCLUSIONS: There exists significant variation in perioperative health care resource usage for CTRs between specialties. Understanding reasons behind such variation would be paramount in minimizing differences in how care is practiced for elective hand procedures.

Challenges in Nerve Repair and Reconstruction.

Peripheral nerve injuries may substantially impair a patient's function and quality of life. Despite appropriate treatment, outcomes often remain poor. Direct repair remains the standard of care when repair is possible without excessive tension. For larger nerve defects, nerve autografting is the gold standard. However, a considerable challenge is donor site morbidity. Processed nerve allografts and conduits are other options, but evidence supporting their use is limited to smaller nerves and shorter gaps. Nerve transfer is another technique that has seen increasing popularity. The future of care may include novel biologics and pharmacologic therapy to enhance regeneration.

To Err is human, but what happens when surgeons Err?

BACKGROUND: Physicians involved in adverse events may suffer from second victim syndrome and can experience emotional and physical distress long after the complication occurred. We sought determine the prevalence of second victim syndrome among surgeons at our children's hospital and evaluate any differences in how surgeons respond to adverse events based on their age, position, and gender. METHODS: An anonymous 19-question questionnaire distributed via institutional emails linking to an anonymous Research Electronic Data Capture (REDCap) survey. Eligible participants included all surgeons and rotating surgical trainees at our hospital. RESULTS: Of 64 faculty surgeons eligible to participate, 63 surveys were returned for a 98% completion rate. Ten additional surveys from surgical trainees were completed for a total of 73 participants. Eighty-four percent reported having had difficulty dealing with a poor outcome or unhappy patient/family. Speaking with a colleague was the most common coping strategy, reported by 82%. Fifty-six percent indicated they believed reporting a poor outcome would have negative ramifications for them. Younger surgeons were more likely to suppress their feelings following an adverse event, and trainees were less likely to advise their peers to speak to a superior about the event (p < 0.05). CONCLUSION: There is a high prevalence of second victim syndrome among surgeons at our children's hospital. There exist differences in ways that surgeons respond to adverse events based on age and position. Healthcare institutions should establish formal mechanisms of support to shift the culture towards one where help is actively sought and offered. LEVEL OF EVIDENCE: IV.

Clinical decision support to Optimize Care of patients with Atrial Fibrillation or flutter in the Emergency department: protocol of a stepped-wedge cluster randomized pragmatic trial (O'CAFÉ trial).

BACKGROUND: Management of adults with atrial fibrillation (AF) or atrial flutter in the emergency department (ED) includes rate reduction, cardioversion, and stroke prevention. Different approaches to these components of care may lead to variation in frequency of hospitalization and stroke prevention actions, with significant implications for patient experience, cost of care, and risk of complications. Standardization using evidence-based recommendations could reduce variation in management, preventable hospitalizations, and stroke risk. METHODS: We describe the rationale for our ED-based AF treatment recommendations. We also describe the development of an electronic clinical decision support system (CDSS) to deliver these recommendations to emergency physicians at the point of care. We implemented the CDSS at three pilot sites to assess feasibility and solicit user feedback. We will evaluate the impact of the CDSS on hospitalization and stroke prevention actions using a stepped-wedge cluster randomized pragmatic clinical trial across 13 community EDs in Northern California. DISCUSSION: We hypothesize that the CDSS intervention will reduce hospitalization of adults with isolated AF or atrial flutter presenting to the ED and increase anticoagulation prescription in eligible patients at the time of ED discharge and within 30 days. If our hypotheses are confirmed, the treatment protocol and CDSS could be recommended to other EDs to improve management of adults with AF or atrial flutter. TRIAL REGISTRATION: ClinicalTrials.gov NCT05009225 .  Registered on 17 August 2021.