Assessing Alternative Approaches for Wound Closure in a National Pediatric Learning Health System.

INTRODUCTION: Our objective was to perform a feasibility study using real-world data from a learning health system (LHS) to describe current practice patterns of wound closure and explore differences in outcomes associated with the use of tissue adhesives and other methods of wound closure in the pediatric surgical population to inform a potentially large study. METHODS: A multi-institutional cross-sectional study was performed of a random sample of patients <18 y-old who underwent laparoscopic appendectomy, open or laparoscopic inguinal hernia repair, umbilical hernia repair, or repair of traumatic laceration from January 1, 2019, to December 31, 2019. Sociodemographic and operative characteristics were obtained from 6 PEDSnet (a national pediatric LHS) children's hospitals and OneFlorida Clinical Research Consortium (a PCORnet collaboration across 14 academic health systems). Additional clinical data elements were collected via chart review. RESULTS: Of the 692 patients included, 182 (26.3%) had appendectomies, 155 (22.4%) inguinal hernia repairs, 163 (23.6%) umbilical hernia repairs, and 192 (27.8%) traumatic lacerations. Of the 500 surgical incisions, sutures with tissue adhesives were the most frequently used (n = 211, 42.2%), followed by sutures with adhesive strips (n = 176, 35.2%), and sutures only (n = 72, 14.4%). Most traumatic lacerations were repaired with sutures only (n = 127, 64.5%). The overall wound-related complication rate was 3.0% and resumption of normal activities was recommended at a median of 14 d (interquartile ranges 14-14). CONCLUSIONS: The LHS represents an efficient tool to identify cohorts of pediatric surgical patients to perform comparative effectiveness research using real-world data to support medical and surgical products/devices in children.

Treatment of Multiple Finger Laceration Caused by Green Onion Cutting Machines in South Korea.

Background: Finger injuries caused by green onion cutting machines in Korean kitchens have unique characteristics of an incomplete amputation in which multiple parallel soft tissues and blood vessels are injured in the same form. In this study, we aimed to describe unique finger injuries and to report the treatment outcomes and experiences of performing possible soft tissue reconstructions. Methods: This case series study included 65 patients (82 fingers) from December 2011 to December 2015. The mean age was 50.5 years. We retrospectively classified the presence of fractures and the degree of damage in patients. The injured area involvement level was categorised as distal, middle or proximal. The direction was categorised as sagittal, coronal, oblique or transverse. The treatment results were compared according to the amputation direction and injury area. Results: Of the 65 patients, 35 had a partial finger necrosis and needed additional surgeries. Finger reconstructions were performed through stump revision or local or free flap use. The survival rate was significantly lower in patients with fractures. As for the injury area, distal involvement led to 17 out of 57 patients displaying necrosis and all 5 patients showing the same in proximal involvement. Conclusions: Unique finger injuries caused by green onion cutting machines can easily be treated with simple sutures. Then prognosis is affected by the extent of injury and the presence of fractures. Reconstruction is necessary for finger necrosis owing to extensive blood vessel damage and limitations when making this selection. Level of Evidence: Level IV (Therapeutic).

Leech Therapy for Complex Facial Lacerations.

ABSTRACT: Facial trauma can pose challenging reconstructive obstacles in both maintaining tissue viability and restoring aesthetic appearance. Medicinal leech therapy can help to promote vascular decompression in the setting of venous congestion. A retrospective chart review was conducted to identify patients who underwent medicinal leech therapy following venous stasis secondary to repair of a complex facial laceration. Three patients were identified; 2 suffered auricular avulsion, while 1 suffered a lip avulsion. All patients suffered from venous congestion and underwent medicinal leech therapy for 48 to 72 hours with reduction of edema and stasis. Decompression was successfully achieved with no further sequelae on last follow-up. Medicinal leech therapy is an adequate treatment for venous congestion following traumatic soft-tissue repair of the face. The authors advocate for the utilization of medicinal leeches to combat venous congestion after repair, particularly when arterial inflow remains intact.

Lidocaine-prilocaine cream versus local infiltration anesthesia in pain relief during repair of perineal trauma after vaginal delivery: a systematic review and meta-analysis.

Background: Perineal trauma is a common problem that may affect women during vaginal delivery; this trauma can be either spontaneous (tear) or intentional (episiotomy). When repair of perineal trauma is required, adequate analgesics must be obtained. Topical products as lidocaine-prilocaine (EMLA) cream is one of the suggested methods, but still there is lack of evidence with regard to its efficacy and safety.Objective: The aim of this review is to assess the evidence of utilizing EMLA cream in comparison to local perineal infiltration anesthesia for pain control during perineal repair after vaginal delivery.Data sources: Medline, Embase, Dynamed Plus, ScienceDirect, TRIP database, ClinicalTrials.gov and the Cochrane Library were searched electronically from January 2006 to May 2018 for studies investigating the effect of lidocaine-prilocaine cream in relieving pain during repair of perineal trauma.Methods of study selection: All randomized controlled trials assessing effect of lidocaine-prilocaine cream versus local infiltration anesthesia in relieving pain during repair of perineal trauma were considered for this meta-analysis. Fifteen studies were identified of which four studies deemed eligible for this review. Quality and risk of bias assessment was performed for all studies.Data extraction: Two researchers independently extracted the data from the individual articles and entered into RevMan software. The weighted mean difference (WMD) and 95% confidence interval (CI) was calculated. Statistical heterogeneity between studies was assessed by the Higgins chi-square and (I2) statistics. When heterogeneity was significant, a random-effects model was used for meta-analysis. Otherwise, the fixed effect meta-analysis was used when there was no significant heterogeneity.Results: Pooled analysis of result in "pain score" was insignificant between the two groups (WMD -1.11; 95% CI (-2.55 to 0.33); p = .13). Furthermore, the use of additional analgesia showed no statistically significant difference between the two groups (WMD 1.34; 95% CI (0.66-2.71), p = .42). Regarding patient satisfaction, an overall analysis of three studies showed significant results favoring EMLA cream group users (WMD 4.65; 95% CI (1.96-11.03), p = .0005). The pooled analysis of the outcome "duration of repair" showed the significantly shorter duration of repair in EMLA cream users (n = 92) than local infiltration anesthesia (n = 95) (1.72 min; 95% CI (-2.76 to -0.67), p = .001).Conclusions: This meta-analysis suggests that topical lidocaine-prilocaine cream gives comparable results in reducing pain during perineal repair after vaginal delivery.

Impact of electronic and blended learning programs for manual perineal support on incidence of obstetric anal sphincter injuries: a prospective interventional study.

BACKGROUND: Obstetric anal sphincter injuries (OASIS) are associated with anal incontinence, dyspareunia and perineal pain. Bimanual perineal support technique (bPST) prevents OASIS. The aim of this study was to assess the effect of two different bPST training-methods on OASIS incidence. METHODS: This is a prospective-interventional quality improvement study conducted in two Palestinian maternity units between June 1 2015 and December 31 2016. Women having spontaneous or operative vaginal-delivery at ≥24 gestational-weeks or a birthweight of ≥1000 g (n = 1694) were recruited and examined vaginally and rectally immediately after vaginal birth by a trained assessor. Data on baseline OASIS incidence were collected during Phase-1 of the study. Subsequently, birth attendants in both maternity units were trained in bPST using two training modalities. A self-directed electronic-learning (e-learning) using an animated video was launched in phase-2 followed by a blended learning method (the animated e-learning video+ structured face-to-face training) in phase-3. OASIS incidence was monitored during phases-2 and 3. Variations in OASIS incidence between the three phases were assessed using Pearson-χ2-test (or Fisher's-Exact-test). The impact of each training-method on OASIS incidence was assessed using logistic-regression analysis. RESULTS: A total of 1694 women were included; 376 in phase-1, 626 in phase-2 and 692 in phase-3. Compared to Phase-1, OASIS incidence was reduced by 45% (12.2 to 6.7%, aOR: 0.56, CI; 0.35-0.91, p = 0.018) and 74% (12.2 to 3.2%, aOR, 0.29, CI; 0.17-0.50, p < 0.001) in phases-2 and 3, respectively. There was also a significant reduction in OASIS incidence by 52% from phase-2 to phase-3 (6.7% (42/626) to 3.2% (22/692), p = 0.003). These reductions reached statistical significance among parous-women only (aOR: 0.18, CI; 0.07-0.49, p = 0.001) after the first training method tested in phase-2. However, the reduction was significant among both primiparous (aOR: 0.39, CI; 0.21-0.74, p = 0.004) and parous-women (aOR: 0.11, CI; 0.04-0.32, p < 0.001) after implementing the blended learning method in phase-3. CONCLUSION: The animated e-learning video had a positive impact on reducing OASIS incidence. However, this reduction was enhanced by the use of a blended learning program combining both e- learning and face-to-face training modalities. STUDY REGISTRATION NUMBER: ClinicalTrialo.gov identifier: NCT02427854 , date: 28 April 2015.

Sealing of Corneal Lacerations Using Photoactivated Rose Bengal Dye and Amniotic Membrane.

PURPOSE: Watertight closure of perforating corneoscleral lacerations is necessary to prevent epithelial ingrowth, infection, and potential loss of the eye. Complex lacerations can be difficult to treat, and repair with sutures alone is often inadequate. In this study, we evaluated a potentially sutureless technology for sealing complex corneal and scleral lacerations that bonds the amniotic membrane (AM) to the wound using only green light and rose bengal dye. METHODS: The AM was impregnated with rose bengal and then sealed over lacerations using green light to bond the AM to the deepithelialized corneal surface. This process was compared with suture repair of 3 laceration configurations in New Zealand White rabbits in 3 arms of the study. A fourth study arm assessed the side effect profile including viability of cells in the iris, damage to the blood-retinal barrier, retinal photoreceptors, retinal pigment epithelium, and choriocapillaris in Dutch Belted rabbits. RESULTS: Analyses of the first 3 arms revealed a clinically insignificant increase in polymorphonuclear inflammation. In the fourth arm, iris cells appeared unaffected and no evidence of breakdown of the blood-retinal barrier was detected. The retina from green light laser-treated eyes showed normal retinal pigment epithelium, intact outer segments, and normal outer nuclear layer thickness. CONCLUSIONS: The results of these studies established that a light-activated method to cross-link AM to the cornea can be used for sealing complex penetrating wounds in the cornea and sclera with minimal inflammation or secondary effects.

Diagnosis and repair of perineal injuries: knowledge before and after expert training-a multicentre observational study among Palestinian physicians and midwives.

OBJECTIVE: To assess whether a 2 days training with experts teaching on diagnosis and repair of perineal injuries among Palestinian midwives and physicians could change their level of knowledge towards the correct diagnosis and treatment. STUDY DESIGN: Multicentre observational study. SETTING: Obstetric departments in 6 government Palestinian hospitals. PARTICIPANTS: All physicians and midwives who attended the training. METHODS: A questionnaire comprising of 14 questions on the diagnosis and repair of perineal tears was distributed to all participants before the training (n=150; 64 physicians and 86 midwives) and 3 months after the training (n=124, 53 and 71, respectively). Characteristics, differences of the study population and level of knowledge before and after the training were presented as frequencies and percentages. Consistency in responses was tested by estimating the p value of McNemar test. RESULTS: Among physicians only 11.4% had accurate knowledge on perineal anatomy before the training compared with 78.85% after the training (p<0.001). For midwives, the corresponding numbers were 9.8% and 54.2%, respectively (p<0.001). Before the training, 5.8% of the physicians were aware that rectal examination is mandatory before and after suturing of episiotomies compared with 45.8% after the training (p<0.001). The corresponding numbers for midwives were 0% and 18% (p<0.001), respectively. Physicians knowledge of best practice of skin repair following episiotomy improved from 36.5% to 64.5% (p=0.008) and among midwives from 26.1% to 50.7% (p<0.001). Physicians knowledge of the overlap technique in the repair of full thickness external anal sphincter tears improved from 28.5% to 42.8% (p=0.05), whereas knowledge of repairing torn internal anal sphincter separately improved from 12.8% to 86.8% (p<0.001). CONCLUSIONS: Improvement in the level of knowledge on diagnosis and repair of perineal tears was observed for all physicians and midwives who attended the 2 days' expert training. Regular ongoing training will serve to maintain the newly acquired knowledge.

Breakdown of Perineal Laceration Repair After Vaginal Delivery: A Case-Control Study.

OBJECTIVE: The aim of the study was to estimate risk factors associated with breakdown of perineal laceration repair after vaginal delivery. METHODS: This is a case-control study of women who sustained a breakdown of perineal laceration repair after vaginal delivery between 2002 and 2015. Cases were patients who sustained a perineal wound breakdown after vaginal delivery and repair of a second-, third-, or fourth-degree laceration. Controls, matched 1:1, were patients who either sustained a second-, third-, or fourth-degree perineal laceration and repair without evidence of breakdown and who delivered on the same day and institution as the case. RESULTS: A total of 104,301 deliveries were assessed for breakdown of perineal laceration. One hundred forty-four met the inclusion criteria. These were matched with 144 controls. Logistic regression analysis demonstrated that smoking is associated with increased risk for breakdown of perineal laceration (adjusted odds ratio [adj. OR], 6.4; 95% confidence interval [CI], 1.2-38.5), whereas a previous vaginal delivery is protective (adj. OR, 0.14; 95% CI, 0.05-0.3). In addition, third- or fourth-degree laceration (adj. OR, 4.0; 95% CI, 1.1-15.7), presence of episiotomy at time of delivery (adj. OR, 11.1; 95% CI, 2.9-48.8), operative delivery (adj. OR, 3.4; 95% CI, 1.2-10.3), midwife performing the laceration repair (adj. OR, 4.7; 95% CI, 1.5-15.8), and use of chromic suture (adj. OR, 3.9; 95% CI, 1.6-9.8) were independent risk factors for breakdown of perineal laceration. CONCLUSIONS: Smoking, nulliparity, episiotomy, operative delivery, third- or fourth-degree laceration, repair by a midwife, and use of chromic suture are independent risk factors for breakdown of perineal laceration repair after vaginal delivery.

A postpartum haemorrhage package with condom uterine balloon tamponade: a prospective multi-centre case series in Kenya, Sierra Leone, Senegal, and Nepal.

OBJECTIVE: To evaluate the effectiveness and safety of an ultra-low-cost uterine balloon tamponade package (ESM-UBT™) for facility-based management of uncontrolled postpartum haemorrhage (PPH) in Kenya, Sierra Leone, Senegal, and Nepal. DESIGN: Prospective multi-centre case series. SETTING: Facilities in resource-scarce areas of Kenya, Sierra Leone, Nepal, and Senegal. POPULATION: Women with uncontrolled postpartum haemorrhage in 307 facilities across the four countries. METHODS: A standardised ESM-UBT package was implemented in 307 facilities over 29 months (1 September 2012 to 1 February 2015). Data were collected via a multi-pronged approach including data card completion, chart reviews, and provider interviews. Beginning in August 2014, women who had previously undergone UBT placement were sought and queried regarding potential complications associated with UBT use. MAIN OUTCOME MEASURES: All-cause survival, survival from PPH, and post-UBT use complications (surgery, hospitalisation, antibiotics for pelvic infection) associated with UBT use. RESULTS: 201 UBTs were placed for uncontrolled vaginal haemorrhage refractory to all other interventions. In all, 38% (71/188) of women were either unconscious or confused at the time of UBT insertion. All-cause survival was 95% (190/201). However, 98% (160/163) of women survived uncontrolled PPH if delivery occurred at an ESM-UBT online facility. One (1/151) potential UBT-associated complication (postpartum endometritis) was identified and two improvised UBTs were placed in women with a ruptured uterus. CONCLUSIONS: These pilot data suggest that the ESM-UBT package is a clinically promising and safe method to arrest uncontrolled postpartum haemorrhage and save women's lives. The UBT was successfully placed by all levels of facility-based providers. Future studies are needed to further evaluate the effectiveness of ESM-UBT in low-resource settings. TWEETABLE ABSTRACT: Evidence for ESM-UBT as a clinically promising and safe method to arrest uncontrolled PPH and save women's lives.

Comparison of local infiltration anesthesia and peripheral nerve block: a randomized prospective study in hand lacerations.

BACKGROUND/AIM: To compare local infiltration anesthesia (LIA) and peripheral nerve block (PNB) in repairing hand lacerations. MATERIALS AND METHODS: This prospective study was designed as a randomized, controlled, unblinded trial. Fifty four patients with hand lacerations were included in the study. While 23 of these patients had LIA, PNB was performed in the remaining 31 patients. Lidocaine hydrochloride 2% and 27 gauge needles were used. Onset time of the anesthesia, response to the injection and suturing procedures, need for additional anesthetic, and patient satisfaction were compared. RESULTS: No significant differences were noted between the groups in terms of response to injection pain and suture pain (Mann-Whitney U; P = 0.220/P = 0.316). There were also no significant differences between the groups when patient satisfaction (chi-square; P = 0.785) and need for additional local anesthetics (Fisher's exact; P = 0.628) were evaluated. The time to loss of pinprick sensation in the local infiltration group was 1.3 min, whereas in the nerve block group it was 2.2 min. The difference was statistically significant (Mann-Whitney U; P < 0.001). CONCLUSION: Despite the fact that performing PNB in emergency departments requires some experience, it still counts as a convenient method comparable to LIA.

Reducing the need for general anaesthesia in children: use of LAT gel in treating facial lacerations.

Facial lacerations in children are common emergencies that often require debridement and closure under general anaesthesia because of poor cooperation by the patient. General anaesthesia in children is not without risk so any technique that avoids its use is beneficial. LAT gel (lidocaine, adrenaline, and tetracaine) is a topical anaesthetic, which is ideal for suturing facial lacerations in children. In our experience its use has resulted in the effective treatment of these injuries, and has reduced distress and discomfort, and the need for hospital admission and general anaesthesia.

Simulating various levels of clinical challenge in the assessment of clinical procedure competence.

STUDY OBJECTIVE: Immersive simulation is increasingly used for competency assessment of emergency physicians. This group's concept of hybrid simulation (HS) (combining simulated patients and part-task trainers (a simulator that simulates a limited component of a clinical procedure) to create a multimodal clinical context) requires clinicians to integrate technical and nontechnical skills in a holistic clinical performance for assessment. It also offers the potential to provide authentic simulation of a given clinical procedure across multiple levels of challenge. The aims of this study are to systematically design and validate 2 patient-focused HS scenarios (each combining a simulated patient with a part-task simulator) for assessment of the management of a commonly encountered problem in an emergency department (ED) at different levels of clinical challenge, and to explore the effect of level of challenge of the HS scenario on physicians' performance. METHODS: A simple (HS1) and a complex (HS2) HS scenario (based on the management of a patient with a traumatic skin laceration within the ED) was developed according to expert opinion through cognitive task analysis. Interns and emergency medicine residents (stratified into expert and novice groups according to experience) were recruited to participate in both scenarios. Participants were randomized to perform either the HS1 or HS2 scenario first. Participants completed a questionnaire for face validity (realism of simulation) and content validity (comprehensiveness of simulation). Performances were assessed by 2 independent raters using validated rating tools modified to the needs of this study: the Modified Objective Structured Assessment of Technical Skills-Task Specific Checklist, the Objective Structured Assessment of Technical Skills-Global Rating Score, and the Direct Observation of Procedural Skills. RESULTS: Ten novice and 10 expert clinicians completed both scenarios. Mean face and content validity ratings were high for both HS1 (mean 4.4 [SD 0.52] and 4.2 [SD 0.48], respectively) and HS2 scenarios (mean 4.5 [SD 0.35] and 4.3 [SD 0.43], respectively). In HS1, no difference was found between experts' and novices' Modified Objective Structured Assessment of Technical Skills-Task Specific Checklist, Objective Structured Assessment of Technical Skills-Global Rating Score, and Direct Observation of Procedural Skills ratings. Experts performed significantly better than novices in HS2 in terms of the 3 tools' ratings. Novices' Modified Objective Structured Assessment of Technical Skills-Task Specific Checklist and Direct Observation of Procedural Skills ratings were significantly worse in HS2 compared with HS1, but no difference was found with the Objective Structured Assessment of Technical Skills-Global Rating Score. No statistical difference was found in experts' Modified Objective Structured Assessment of Technical Skills-Task Specific Checklist, Objective Structured Assessment of Technical Skills-Global Rating Score, and Direct Observation of Procedural Skills ratings between HS2 and HS1 scenarios. CONCLUSION: Recreating clinical challenge is an important consideration in the design of simulation-based assessment of procedural skills of clinicians. In this study, we have demonstrated a systematic approach to developing HS scenarios, which may be able to recreate various levels of clinical challenge for purpose of assessment of procedural skills.

The "sweet science" of reducing periorbital lacerations in mixed martial arts.

The popularity of mixed martial arts competitions and televised events has grown exponentially since its inception, and with the growth of the sport, unique facial injury patterns have surfaced. In particular, upper eyelid and brow lacerations are common and are especially troublesome given the effect of hemorrhage from these areas on the fighter's vision and thus ability to continue. We propose that the convexity of the underlying supraorbital rim is responsible for the high frequency of lacerations in this region after blunt trauma and offer a method of reducing subsequent injury by reducing its prominence.

Preliminary clinical assessment of polyvinyl alcohol-tetrahydroxyborate hydrogels as potential topical formulations for local anesthesia of lacerations.

OBJECTIVES: The aim of this study was to assess a novel semisolid material as a potential topical drug delivery system for acute laceration. The objectives were to correlate physical characterization data using rheologic studies and to compare with clinical assessment of performance in an emergency department (ED). METHODS: Polyvinyl alcohol (PVA) hydrogels, cross-linked using tetrahydroxyborate (THB), were characterized using texture profile analysis. Formulation samples were applied to acute lacerations presented to the ED and factors, such as in vivo residency time and cohesive removal, were assessed. RESULTS: Viscosity was shown to be related to mechanical characteristics, whereas adhesiveness depended on the THB concentration. Residence in, and clean removal from, lacerations was evaluated on 29 patients. Formulation F3 (10.0% PVA, 2.5% w/w THB) displayed the most appropriate characteristics for clinical use by scoring highest in qualitative assessments. Other formulations exhibited difficulties in application and removal due to excessive adhesiveness. The release of a model local anesthetic drug was proportional to the concentration of drug incorporated, but was not substantially affected by small changes in the formulation constituents. CONCLUSIONS: Using a combination of pharmaceutical evaluation and clinical assessment, it was shown that cross-linked PVA semisolids are a suitable formulation for drug administration to acute lacerations, with potential for induction of anesthesia prior to wound repair.

Use of topical as only anesthetic for suturing a traumatic facial laceration.

A case is described where only topical anesthetic was used for suturing facial lacerations. The patient had sustained facial lacerations after a motor vehicle accident. After some initial treatment the patient refused injection anesthesia so only topical anesthetics lidocaine-prilocaine was used for one of the lacerations. Suturing was possible to perform with only topical anesthesia with good patient comfort.

Surgical debridement of mineral pitch and nonviable penile tissue using water-jet power: a preliminary report.

OBJECTIVE: To report our experience of debriding genital wounds embedded with mineral pitch (MP) from asphalt, using a water jet-powered surgical tool, the Versajet Hydrosurgery System (VHS, Smith and Nephew, Key Largo, FL) before reconstruction. PATIENTS AND METHODS: We used the VHS for penile debridement in two patients. The first was 42-year-old Hispanic man involved in a truck-bike accident, who was dragged approximately 60 m after the collision. He presented with 25% body-surface abrasion impregnated with MP. The scrotal soft tissue had been lost and both testicles were exposed and ruptured, with no viable tissue. Moreover, the distal two-thirds of the penile urethra and the ventral glans were completely damaged and his penis entirely degloved. Several procedures were required for surgical debridement and reconstruction, including the skin grafting to 25% of his body surface. All surgical debridement was done with the VHS. A modified Thiersch-Duplay urethroplasty was used over a 16 F Foley catheter to reconstruct the missing urethra. The second patient was a 32-year-old man with no previous medical history, who presented with Fournier's gangrene after a penile abrasion following unprotected sexual intercourse. He required several surgical debridements. The VHS was applied to an 8 x 10 cm area, followed by a free-radial graft to the inferior epigastric. RESULTS: The clinical follow-up was 9 and 6 months, respectively; both patients had satisfactory granulation tissue and proper wound healing. Neither of the patients had infection after surgical debridement with the VHS, even when used in the case of Fournier's gangrene. CONCLUSION: The VHS appears to be effective for genital soft-tissue surgical debridement even when the tissue is impregnated with MP or infected, without causing any spread of infection. Larger series and a longer follow-up are needed to validate the effectiveness of the VHS in managing complex genital wounds.

The effect of music on parental participation during pediatric laceration repair.

The purpose of this quasi-experimental study was to test an intervention on the use of music during simple laceration repair to promote parent-led distraction in children aged 1 to 5. Children's songs were broadcast via speakers during laceration repair and parents were encouraged to participate in distracting their child. The proportion of parental participation was determined. Laceration procedures were videotaped and objectively scored using the Procedure Behavior Check List. A total of 57 children participated in the study. There was no difference in parental involvement between the control and intervention groups. When age, sex, and condition were controlled for, distress scores were significantly higher if the father was present in the procedure room than if only the mother was present (43.68 vs. 23.39, t(54) 4.296, p = < 0.001). It was concluded that distress varies with the age of the child and the parent who is present during the procedure. Providing music during simple laceration repair did not increase the proportion of parents who were involved in distraction.

Risk factors associated with anal sphincter tear difference among midwife, private obstetrician, and resident deliveries.

To identify risk factors that account for the difference in anal sphincter tear (AST) among midwife, private obstetrician, and resident deliveries. We performed a retrospective review of our obstetrical database and used logistic regression analysis to identify risk factors for AST. The relationship between delivery technique and AST was evaluated by comparing AST increase between vaginal deliveries without and with an episiotomy among the three categories of providers. After adjusting for risk factors, private obstetricians (OR: 1.81, 95% CI: 1.27-2.56) and residents (OR: 1.60, 95% CI: 1.20-2.15) had a higher rate of AST during vaginal delivery than midwives. Episiotomy increased the odds of AST by four-fold for midwives, two-fold for private obstetricians, and eight-fold for residents. Although midwife and resident's delivery methods were associated with more AST, neither experienced this complication more frequently than private obstetricians. This suggests that midwives and residents probably misdiagnosed some AST.