Gender bias in reference letters for residency and academic medicine: a systematic review.

Reference letters play an important role for both postgraduate residency applications and medical faculty hiring processes. This study seeks to characterise the ways in which gender bias may manifest in the language of reference letters in academic medicine. In particular, we conducted a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched Embase, MEDLINE and PsycINFO from database inception to July 2020 for original studies that assessed gendered language in medical reference letters for residency applications and medical faculty hiring. A total of 16 studies, involving 12 738 letters of recommendation written for 7074 applicants, were included. A total of 32% of applicants were women. There were significant differences in how women were described in reference letters. A total of 64% (7/11) studies found a significant difference in gendered adjectives between men and women. Among the 7 studies, a total of 86% (6/7) noted that women applicants were more likely to be described using communal adjectives, such as "delightful" or "compassionate", while men applicants were more likely to be described using agentic adjectives, such as "leader" or "exceptional". Several studies noted that reference letters for women applicants had more frequent use of doubt raisers and mentions of applicant personal life and/or physical appearance. Only one study assessed the outcome of gendered language on application success, noting a higher residency match rate for men applicants. Reference letters within medicine and medical education exhibit language discrepancies between men and women applicants, which may contribute to gender bias against women in medicine.

Effect of Time-To-Surgery on Distal Radius Fracture Outcomes: A Systematic Review.

PURPOSE: It remains unclear whether time-to-surgery for distal radius fractures affects clinical, functional, or radiographic outcomes or health care costs/use. This systematic review investigated the outcomes of early versus delayed surgery for closed, isolated distal radius fractures in adult patients. METHODS: A comprehensive search of MEDLINE, Embase, and CINAHL databases was completed for all original case series, observational studies, and randomized controlled trials reporting clinical outcomes of both early and delayed surgically-treated distal radius fractures from database inception to July 01, 2022. A consistent threshold of two weeks was used to define early versus delayed treatment arms. RESULTS: Nine studies, including 16 intervention arms and 1,189 patients (858 early, 331 delayed), were included. Mean age was 58 years (range, 33-76). At more than one year, the frequency-weighted mean Disabilities of the Arm, Shoulder, and Hand score was 4 in the early group (n = 208; range, 1-17) and 21 in the delayed group (n = 181; range, 4-27). Range of motion, grip strength, and radiographic outcomes were comparable. The pooled mean complication rate (7% vs 5%) and revision rate (3.6% vs 1%) were very low in both groups. CONCLUSIONS: A delay in time-to-surgery greater than two weeks for distal radius fractures may be associated with inferior patient-reported outcomes. Early surgery was associated with improved long-term Disabilities of the Arm, Shoulder, and Hand scores. On the basis of the available evidence, range of motion, grip strength, and radiographic outcomes are similar. The complication and revision rates were very low in both groups and comparable. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Leg Ulcers: A Report in Patients with Hemoglobin E Beta Thalassemia and Review of the Literature in Severe Beta Thalassemia.

BACKGROUND: Leg ulcers are a frequent complication in patients with the inherited hemoglobin disorders. In thalassemia, the literature is limited, and factors associated with the development of leg ulcers in hemoglobin E (HbE) beta thalassemia, the most common form of severe beta-thalassemia worldwide, have not previously been reported. METHODS: We reviewed all available medical records of patients with HbE beta thalassemia to document the onset of leg ulcers at the 2 largest treatment centers in Sri Lanka. We reviewed the literature to identify studies reporting outcomes of interventions for ulcers in severe thalassemia. RESULTS: Of a total of 255 actively registered patients with HbE thalassemia in the 2 centers, 196 patient charts were evaluable. A leg ulcer with a documented date of onset was recorded in 45 (22%) of 196 evaluable patients, aged (mean ± SEM) 22.2 ± 1.4 years. Most had been irregularly transfused; steady-state hemoglobin was 6.4 ± 0.2 g/dL. Treatment achieving healing in 17 patients included transfusions, antibiotics, oral zinc, wound toileting, and skin grafting. CONCLUSION: Leg ulcers may be more common in HbE beta thalassemia than in other forms of thalassemia. A systematic approach to treatment will be needed to document the prevalence and factors placing such patients at risk for leg ulcers. Controlled trials to evaluate the optimal treatment of this common complication are indicated.

A systematic review and meta-analysis of the long-term outcomes of endovascular versus open repair of abdominal aortic aneurysm.

OBJECTIVE: This study synthesized the literature comparing the long-term (5-9 years) and very long-term (≥10 years) all-cause mortality, reintervention, and secondary rupture rates between endovascular aneurysm repair (EVAR) and open surgical repair (OSR) of abdominal aortic aneurysm (AAA). METHODS: MEDLINE, Embase, and CENTRAL databases were searched from inception to May 2018 for studies comparing EVAR to OSR with a minimum follow-up period of 5 years. Study selection, data abstraction, and quality assessment were conducted by two independent reviewers, with a third author resolving discrepancies. Study quality was assessed using the Cochrane and Newcastle-Ottawa scales. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random-effects models. Heterogeneity was quantified using the I2 statistic, and publication bias was assessed using funnel plots. RESULTS: Our search yielded 3431 unique articles. Three randomized controlled trials and 68 observational studies comparing 151,092 EVAR to 148,692 OSR patients were included. Inter-rater agreement was excellent at the screening (κ = 0.78) and full-text review (κ = 0.89) stages. Overall, the risk of bias was low to moderate. For long-term outcomes, 54 studies reported all-cause mortality (n = 203,246), 23 reported reintervention (n = 157,151), and 4 reported secondary rupture (n = 150,135). EVAR was associated with higher long-term all-cause mortality (OR, 1.19; 95% CI, 1.06-1.33; P = .003, I2 = 91%), reintervention (OR, 2.12; 95% CI, 1.67-2.69; P < .00001, I2 = 96%), and secondary rupture rates (OR, 4.84; 95% CI, 2.63-8.89; P < .00001, I2 = 92%). For very long-term outcomes, 15 studies reported all-cause mortality (n = 48,721), 9 reported reintervention (n = 7511), and 1 reported secondary rupture (n = 1116). There was no mortality difference between groups, but EVAR was associated with higher reintervention (OR, 2.47; 95% CI, 1.71-3.57; P < .00001, I2 = 84%) and secondary rupture rates (OR, 8.10; 95% CI, 1.01-64.99; P = .05). Subanalysis of more recent studies, with last year of patient recruitment 2010 or after, demonstrated no long-term mortality differences between EVAR and OSR. CONCLUSIONS: EVAR is associated with higher long-term all-cause mortality, reintervention, and secondary rupture rates compared with OSR. In the very long-term, EVAR is also associated with higher reintervention and secondary rupture rates. Notably, EVAR mortality has improved over time. Vigilant long-term surveillance of EVAR patients is recommended.

The Current Status of Lithoplasty in Vascular Calcifications: A Systematic Review.

Background. Lithoplasty is a method of alleviating vessel stenosis by using localized high-speed pressure waves to disrupt calcium deposits. A systematic review of the literature was performed to summarize the early outcomes of lithoplasty in peripheral and coronary artery disease. Methods. We searched EMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials from database inception to July 2018 for original studies describing the use of lithoplasty. Study selection and data extraction were performed in duplicate, with a third author resolving discrepancies. Results. A total of 9 records were included from the 201 studies eligible for screening. In total, 211 patients with vascular calcification lesions underwent lithoplasty. The patients on average had an age of 73.2 years and had a maximum follow-up period of 5.5 months. Most lesions (72%, 152/212) were in peripheral artery beds, with the remainder occurring in coronary vessels. Lesioned vessels typically had severe calcium burden 62.6% (131/210), with an average initial stenosis of 76.6% (range, 68.1%-77.8%). After treatment, the average residual stenosis was 21.0% (range, 13.3%-26.2%), with a mean acute gain of vessel diameter of 2.5 mm. A limited number of type D dissections occurred, with a total of 2.4% (5/211) of patients requiring stent implantation. Conclusions. Recent studies suggest that lithoplasty is a promising intervention to decrease vessel stenosis in both peripheral artery disease and coronary artery disease, with minimal occurrence of major adverse events. Further research studies, with more rigorous study designs, are needed to determine the effectiveness of lithoplasty in vascular calcifications.

Level of clinical evidence presented at the Society for Vascular Surgery Annual Meeting during a 5-year period (2012-2016).

OBJECTIVE: During the past decades, there has been an increasing emphasis on the use of high-quality evidence to inform clinical decision-making. The purpose of our study was to assess trends in the level of evidence (LOE) of abstracts presented at the Vascular Annual Meeting from 2012 to 2016. METHODS: All Vascular Annual Meeting abstracts for 2012 to 2016 were obtained through the Journal of Vascular Surgery. Two reviewers independently screened abstracts for eligibility. Research with a nonclinical focus was excluded from the study. Data extracted from eligible abstracts included study type (therapeutic, prognostic, diagnostic), study size, country of academic institution of primary author, presentation type, and whether the sample was recruited or from a database. Abstracts were assigned an LOE using the 2011 Oxford Centre for Evidence-Based Medicine classification scheme based on study design (eg, case series, randomized controlled trial). A χ2 test and analysis of variance test were conducted to assess nonrandom changes in LOE during the study period. RESULTS: Of the 1403 abstracts screened, 1147 were included. Inter-rater agreement was high (κ value for abstract screening was 0.93; κ value for data extraction was 0.89). Therapeutic studies were the most common study type (58%), followed by prognostic studies (37%), then diagnostic studies (5%). The majority of abstracts (75.0%) were submitted from North American institutions. Overall, 0.35% of the presentations were level I evidence, 3.1% level II, 52.8% level III, 38.0% level IV, and 5.7% level V. The average LOE per year fluctuated between 3.54 and 3.32, with a mean LOE of 3.45. The proportion of high-quality evidence (level I and level II) increased in the years 2015 and 2016, representing 78% of all level I and level II abstracts presented in the 5-year period. A χ2 test between LOE and year yielded a P value of .0084, indicating significant nonrandom change in LOE between 2012 and 2016. The majority of high LOE research was presented in poster sessions (37.5%), plenary sessions (27.5%), and international forum sessions/talks (25%) at the meeting. CONCLUSIONS: Overall, average LOE remained relatively consistent between 2012 and 2016, with most abstracts classified as level III or level IV. There was a gradual, albeit minor, increase in the proportion of level I and level II evidence in 2015 and 2016, potentially indicating the increasing commitment to producing and disseminating high-level research in vascular surgery. Furthermore, a lack of a classification tool specific to vascular surgery research occasionally presented a challenge in assigning LOE, perhaps indicating a need for such a tool in this specialty.

The role of routine cardiac investigations before hyperbaric oxygen treatment.

Cardiac complications are a rare but potentially serious consequence of hyperbaric oxygen treatment (HBOT), resulting from increased blood pressure and decreased heart rate and cardiac output associated with treatment. These physiologic changes are generally well-tolerated by patients without preexisting cardiac conditions, although those with known or undetected cardiac disease may be more vulnerable to treatment complications. Currently, there are no universally accepted guidelines for pre-HBOT cardiac screening to identify these patients at heightened risk, leading to variability in practice patterns. In the absence of HBOT-specific evidence, screening protocols might be adapted from the diving medicine community; however, given the important differences in physiological stressors, these may not be entirely applicable to patients undergoing HBOT. Traditional cardiac investigations such as electro- and echo-cardiograms are limited in their ability to detect relevant risk modifying states in the pre-HBOT patient, stymieing their cost-effectiveness as routine tests. In the absence of strong evidence to support routine cardiac investigation, we argue that a comprehensive history and physical exam - tailored to identify high-risk patients based on clinical parameters - may serve as a more practical screening tool. While certain unique patient groups such as those undergoing dialysis or with implanted cardiac devices may warrant specialised assessment, thorough evaluation may be sufficient to identify many patients unlikely to benefit from cardiac investigation in the pre-HBOT setting. A clinical decision-making tool based on suggested low-risk and high-risk features is offered to guide the use of targeted cardiac investigation prior to HBOT.

Chronic aryl hydrocarbon receptor activity impairs muscle mitochondrial function with tobacco smoking.

BACKGROUND: Accumulating evidence has demonstrated that chronic tobacco smoking directly contributes to skeletal muscle dysfunction independent of its pathological impact to the cardiorespiratory systems. The mechanisms underlying tobacco smoke toxicity in skeletal muscle are not fully resolved. In this study, the role of the aryl hydrocarbon receptor (AHR), a transcription factor known to be activated with tobacco smoke, was investigated. METHODS: AHR related gene (mRNA) expression was quantified in skeletal muscle from adult controls and patients with chronic obstructive pulmonary disease (COPD), as well as mice with and without cigarette smoke exposure. Utilizing both skeletal muscle-specific AHR knockout mice exposed to chronic repeated (5 days per week for 16 weeks) cigarette smoke and skeletal muscle-specific expression of a constitutively active mutant AHR in healthy mice, a battery of assessments interrogating muscle size, contractile function, mitochondrial energetics, and RNA sequencing were employed. RESULTS: Skeletal muscle from COPD patients (N = 79, age = 67.0 ± 8.4 years) had higher levels of AHR (P = 0.0451) and CYP1B1 (P < 0.0001) compared to healthy adult controls (N = 16, age = 66.5 ± 6.5 years). Mice exposed to cigarette smoke displayed higher expression of Ahr (P = 0.008), Cyp1b1 (P < 0.0001), and Cyp1a1 (P < 0.0001) in skeletal muscle compared to air controls. Cigarette smoke exposure was found to impair skeletal muscle mitochondrial oxidative phosphorylation by ~50% in littermate controls (Treatment effect, P < 0.001), which was attenuated by deletion of the AHR in muscle in male (P = 0.001), but not female, mice (P = 0.37), indicating there are sex-dependent pathological effects of smoking-induced AHR activation in skeletal muscle. Viral mediated expression of a constitutively active mutant AHR in the muscle of healthy mice recapitulated the effects of cigarette smoking by decreasing muscle mitochondrial oxidative phosphorylation by ~40% (P = 0.003). CONCLUSIONS: These findings provide evidence linking chronic AHR activation secondary to cigarette smoke exposure to skeletal muscle bioenergetic deficits in male, but not female, mice. AHR activation is a likely contributor to the decline in muscle oxidative capacity observed in smokers and AHR antagonism may provide a therapeutic avenue aimed to improve muscle function in COPD.

Hand and Wrist Injuries Associated With Application of Physical Restraints: A Systematic Review.

While handcuffs and zip ties are common methods of physical restraint used by law enforcement, they have been noted to damage soft tissue and bony structures of the hand and wrist. This paper seeks to characterize the safety of physical restraints by summarizing its effects on hand and wrist function and disability. Relevant studies were gathered through an independent double selection and extraction process using 3 electronic databases (EMBASE, MEDLINE, and CINAHL) from database inception to June 19, 2020. A total of 16 studies involving 807 participants were included. Lesion to the superficial branch of the radial nerve was the most commonly reported injury noted in 82% (42/55) of hands examined. A total of 6% (5/77) of examined hands had bony injury, including 3 radial styloid fractures and 2 scaphoid fractures. Both studies on zip ties noted presence of handcuff neuropathy, with 1 case report documenting severe rapidly progressing ischemic monomelic neuropathy. Overall, the use of handcuffs and zip ties is associated with entrapment neuropathies and bony injury to the hand and wrist. Further studies of higher quality evidence are necessary to understand the effects of physical restraint on hand function and disability.

The role of hyperbaric oxygen therapy in the management of perioperative peripheral nerve injury: a scoping review of the literature.

BACKGROUND/IMPORTANCE: Peripheral nerve injury is an uncommon but potentially catastrophic complication of anesthesia and surgery, for which there are limited effective treatment options. Hyperbaric oxygen therapy is a unique medical intervention which improves tissue oxygen delivery and reduces ischemia via exposure to oxygen at supra-atmospheric partial pressures. While the application of hyperbaric oxygen therapy has been evidenced for other medical conditions involving relative tissue ischemia, its role in the management of peripheral nerve injury remains unclear. OBJECTIVE: This scoping review seeks to characterize rehabilitative outcomes when hyperbaric oxygen therapy is applied as an adjunct therapy in the treatment of perioperative peripheral nerve injury. EVIDENCE REVIEW: The review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for scoping reviews, using a systematic screening and extraction process. The search included articles published from database inception until June 11, 2022, which reported clinical outcomes (in both human and non-human models) of peripheral nerve injury treated with hyperbaric oxygen therapy. FINDINGS: A total of 51 studies were included in the narrative synthesis. These consisted of animal (40) and human studies (11) treating peripheral nerve injury due to various physiological insults. Hyperbaric oxygen therapy protocols were highly heterogenous and applied at both early and late intervals relative to the time of peripheral nerve injury. Overall, hyperbaric oxygen therapy was reported as beneficial in 88% (45/51) of included studies (82% of human studies and 90% of animal studies), improving nerve regeneration and/or time to recovery with no reported major adverse events. CONCLUSIONS: Existing data suggest that hyperbaric oxygen therapy is a promising intervention in the management of perioperative peripheral nerve injury, in which tissue ischemia is the most common underlying mechanism of injury, neurological deficits are severe, and treatment options are sparse. This positive signal should be further investigated in prospective randomized clinical trials.

Successful treatment of neurologic injury after complex spinal surgery with hyperbaric oxygen therapy: a case report.

Background: Neurologic injury is relatively common in the context of spinal surgery, and is often treated with physiotherapy, pharmacotherapy, or surgical intervention. Emerging evidence supports a possible role for hyperbaric oxygen therapy (HBOT) in the treatment of peripheral and spinal nerve injuries. We describe the successful use of HBOT in improving neurologic recovery after complex spine surgery with new-onset postoperative unilateral foot drop. Case Description: A 50-year-old woman was found to have new right-sided foot drop and L2-S1 motor deficits following complex thoracolumbar revision spinal surgery. She received standard conservative management for a provisional diagnosis of acute traumatic nerve ischemia, but demonstrated no neurologic improvement. On postoperative day four, after other avenues of treatment were exhausted, she was referred for HBOT. The patient received a total of twelve sessions of HBOT at 2.0 absolute atmospheres (ATA) of pressure, for 90 minutes (including two air breaks) per session, before transfer to a rehabilitation facility. Conclusions: The patient displayed marked neurologic improvement after the first hyperbaric session, and further recovery thereafter. She concluded therapy with a significantly improved range of motion and lower limb power, ability to ambulate, and pain control. HBOT was associated with a rapid, sustained improvement when applied in this case as a salvage therapy for persistent postoperative neurologic deficit. Mounting evidence supports the consideration of hyperbaric therapy as a standard adjunct treatment for traumatic neurologic injury.

Accuracy of Heart Rate Measurement with Wrist-Worn Wearable Devices in Various Skin Tones: a Systematic Review.

BACKGROUND: Wearable consumer technology allows for the collection of a growing amount of personal health data. Through the analysis of reflected LED light on the skin, heart rate measurement and arrhythmia detection can be performed. Given that melanin alters skin light absorption, this study seeks to summarize the accuracy of cardiac data from wrist-worn wearable devices for participants of varying skin tones. METHODS: We conducted a systematic review, searching Embase, MEDLINE, CINAHL, and Cochrane for original studies that stratified heart rate and rhythm data for consumer wearable technology according to participant race and/or skin tone. RESULTS: A total of 10 studies involving 469 participants met inclusion criteria. The frequency-weighted Fitzpatrick score for skin tone was reported in six studies (n = 293), with a mean participant score of 3.5 (range 1-6). Overall, four of the ten studies reported a significant reduction in accuracy of heart rate measurement with wearable devices in darker-skinned individuals, compared to participants with lighter skin tones. Four studies noted no effect of user skin tone on accuracy. The remaining two studies showed mixed results. CONCLUSIONS: Preliminary evidence is inconclusive, but some studies suggest that wearable devices may be less accurate for detecting heart rate in participants with darker skin tones. Higher quality evidence is necessary, with larger sample sizes and more objective stratification of participants by skin tone, in order to characterize potential racial bias in consumer devices.

Integrating Public Health Into Undergraduate Medicine in North America: A Systematic Review.

The coronavirus disease 2019 (COVID-19) pandemic has served as a stark reminder of the importance of foundational public health training for all physicians. However, the most effective way to incorporate these concepts into undergraduate medical education remains unclear. Here, we characterize the literature regarding the effectiveness of public health integration into undergraduate medical education in North America. We systematically searched MEDLINE, Embase, Cochrane Central, and Education Resources Information Center (ERIC) in accordance with preferred reporting items for systematic review and meta-analysis (PRISMA) guidelines for North American peer-reviewed literature, published from 01/01/2000 to 30/08/2021, that described outcomes of integrating public health training within an undergraduate medical curriculum. Results were qualitatively synthesized into key themes. A total of 38 studies, involving interventions across 43 medical schools, were included. Studies reported on a combination of public (n=13), global (n=9), population (n=9), community (n=6), and epidemiological (n=1) health interventions, and either implemented one-off workshops, electives, or international experiences (n=19); a longitudinal theme or long-term enrichment pathway (n=14); or a case-based learning curriculum (n=8). The majority (81.5%, 31/38) of integrations were self-described as successful and, of studies reporting on feasibility, most (94.1%, 16/17) were indicated as feasible. The definition of what constituted such success, however, was unclear. Innovative examples included the use of simulation workshops and mobile-optimized media content. Key challenges were noted, however, in securing adequate funding and buy-in from administrative leadership. Robust community partnerships and iterative cycles of implementation of the intervention were critical factors to success. In summary, foundational public health components can be effectively integrated into medical school curricula and would benefit from adequate resourcing, innovation, community partnerships, and continuous improvement.

Association between perioperative neuraxial local anesthetic neurotoxicity and arachnoiditis: a narrative review of published reports.

BACKGROUND/IMPORTANCE: Arachnoiditis is a rare but devastating disorder caused by various insults, one of which is purported to be local anesthetic neurotoxicity following neuraxial blockade. However, the relationship between local anesthetics administered into the neuraxis and the development of arachnoiditis has not been clearly elucidated. OBJECTIVE: We aimed to summarize the existing complex body of literature and characterize both the essential features and strength of any association between neuraxial local anesthetic neurotoxicity and arachnoiditis with a view toward mitigating risk, enhancing prevention, and refining informed consent discussions. EVIDENCE REVIEW: We reviewed all published reports of arachnoiditis attributed to local anesthetic neurotoxicity following perioperative neuraxial anesthesia. This narrative review was based on a systematic search methodology, which included articles published up until December 2022. FINDINGS: Thirty-eight articles were included, comprising 130 patients, over one-half of which were published prior to this century and inconsistent with modern practice. Neuraxial techniques included 78 epidurals, 48 spinals, and 5 combined spinal-epidurals, mostly for obstetrics. Reporting of essential procedural data was generally incomplete. Overall, at least 57% of patients experienced complicated needle/catheter insertion, including paresthesia, pain, or multiple attempts, irrespective of technique. The onset of neurological symptoms ranged from immediate to 8 years after neuraxial blockade, while the pathophysiology of arachnoiditis, if described, was heterogeneous. CONCLUSIONS: The existing literature attributing arachnoiditis to local anesthetic neurotoxicity is largely outdated, incomplete, and/or confounded by other potential causes, and thus insufficient to characterize the features and strength of any association.

Functional and patient-reported outcomes following single digit replantation: A systematic literature review.

OBJECTIVES: Finger amputations can involve different levels of injury complexity, and the success of a finger replantation is further shaped by a variety of factors, including patient characteristics, surgical technique, and postoperative rehabilitation. These variables may interact in complex ways and contribute to heterogeneity that makes it challenging to guide management for individual patients. As such, this systematic review seeks review the outcomes of isolated single digit replantation and compare patient reported outcomes following revision amputation to guide decision making. METHODS: The United States National Library of Medicine (PubMed/Medline), EMBASE and CINAHL were systematically searched to identify publications relevant to this systematic review. Related articles that were published from database inception to October 15, 2022 were extracted. The inclusion criteria consisted of English language clinical trials and observational studies reporting any functional or patient-reported outcome following single digit replantation. RESULTS: From the initial 1050 titles and abstracts that were eligible for screening, six studies representing 550 single digit replantations were included. There were 162 replanted thumbs (162/550), as reported in three studies, and 388 replanted fingers (388/550), as reported in all six studies. Overall, all six studies concluded that non-thumb single digit replantation can provide satisfactory outcomes. Five studies suggested that single digit replantation proximal to flexor zone II can have reasonable outcomes in select cases. Two of the comparative studies (Zhu et al. [1], Chung et al. [2]) showed a statistically significant increase in MHQ score in the non-thumb replant group in comparison to the revision amputation group (87.6 versus 84.6 respectively). CONCLUSION: When technically feasible, replantation is recommended, even in select index finger zone II amputations. Single digit replantation does not restore pre-injury hand function but does result in acceptable hand function when successful. Further study is needed to better inform risk-stratification of patients, and guide patient, and surgeon expectations for post-operative recovery. LEVEL OF EVIDENCE: III.

Meta-Analysis of Long-Term (>1 Year) Cardiac Outcomes of Peripartum Cardiomyopathy.

Peripartum cardiomyopathy is the development of heart failure toward the end of pregnancy or in the months after delivery in the absence of other attributable causes, with left ventricular systolic dysfunction and a left ventricular ejection fraction (LVEF) generally <45%. Given that patients are relatively young at the time of diagnosis, this study was performed to summarize current evidence surrounding the long-term cardiac outcomes. MEDLINE, Embase, Cochrane CENTRAL, and CINAHL were searched for original studies that reported long-term (>1 year) patient outcomes. Of the 3,144 total records identified, 62 studies involving 4,282 patients met the selection criteria. The mean LVEF was 28% at diagnosis and 47% at the time of the last follow-up. Approximately half of the patients achieved myocardial recovery (47%), most commonly defined as an LVEF >50% (n = 21). The prevalence of implantable cardioverter-defibrillator use, left ventricular assist device implantation, and heart transplantation was 12%, 7%, and 11%, respectively. The overall all-cause mortality was 9%, and despite having more cardiovascular risk factors, patients residing in high-income countries had superior outcomes, including reduced rates of mortality.

Pulmonary function following hyperbaric oxygen therapy: A longitudinal observational study.

Hyperbaric oxygen therapy (HBOT) is known to be associated with pulmonary oxygen toxicity. However, the effect of modern HBOT protocols on pulmonary function is not completely understood. The present study evaluates pulmonary function test changes in patients undergoing serial HBOT. We prospectively collected data on patients undergoing HBOT from 2016-2021 at a tertiary referral center (protocol registration NCT05088772). Patients underwent pulmonary function testing with a bedside spirometer/pneumotachometer prior to HBOT and after every 20 treatments. HBOT was performed using 100% oxygen at a pressure of 2.0-2.4 atmospheres absolute (203-243 kPa) for 90 minutes, five times per week. Patients' charts were retrospectively reviewed for demographics, comorbidities, medications, HBOT specifications, treatment complications, and spirometry performance. Primary outcomes were defined as change in percent predicted forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and forced mid-expiratory flow (FEF25-75), after 20, 40, and 60 HBOT sessions. Data was analyzed with descriptive statistics and mixed-model linear regression. A total of 86 patients were enrolled with baseline testing, and the analysis included data for 81 patients after 20 treatments, 52 after 40 treatments, and 12 after 60 treatments. There were no significant differences in pulmonary function tests after 20, 40, or 60 HBOT sessions. Similarly, a subgroup analysis stratifying the cohort based on pre-existing respiratory disease, smoking history, and the applied treatment pressure did not identify any significant changes in pulmonary function tests during HBOT. There were no significant longitudinal changes in FEV1, FVC, or FEF25-75 after serial HBOT sessions in patients regardless of pre-existing respiratory disease. Our results suggest that the theoretical risk of pulmonary oxygen toxicity following HBOT is unsubstantiated with modern treatment protocols, and that pulmonary function is preserved even in patients with pre-existing asthma, chronic obstructive lung disease, and interstitial lung disease.

Factors associated with early and late digital revascularization and replantation failure: a retrospective cohort study.

Factors associated with failure of digital revascularization and replantation procedures have been well characterized, but studies have not investigated failures occurring beyond the early postoperative period. A single-centre retrospective chart review included 284 patients (434 digits) who underwent digital revascularization or replantation. Patient-, injury- and surgery-related characteristics were compared among successful procedures, digits that failed while in hospital (early failure), and initially viable digits that failed after hospital discharge (late failure). Overall, 202 patients had successful procedures (71%). There were 51 early failures (18%) and 31 late failures (11%). Crush injuries and vein grafting were associated with early failure only. Complete amputations and leeching were strongly associated with both early and late failure. This study revealed that a substantial proportion of initially viable digits fail after discharge from hospital. Patients with signs of venous congestion may benefit from longer observation periods in hospital to avoid late failure.Level of evidence: IV.

Educational interventions to improve hepatitis C testing or treatment in South Asian communities: A systematic review.

BACKGROUND: Hepatitis C (HCV) places a disproportionately higher burden on the South Asian community in comparison to the general population, despite the availability of effective antiviral therapies. This study seeks to characterize the effectiveness of health promotion initiatives aimed at South Asians to improve HCV prevention, education, screening, and treatment adherence. METHODS: A systematic review (PROSPERO: CRD42021253796) was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Ovid MEDLINE, CINAHL Plus, Web of Science, ERIC, Ovid Embase, Cochrane Library, and PsycINFO were searched from inception to 15 April 2022 for original studies that reported on any health promotion initiative directed at improving HCV outcomes in the South Asian community. Risk of bias was assessed via a quality score. RESULTS: A total of 15 studies (6 uncontrolled interventional, 3 before-after interventional, 3 randomized controlled, 2 prospective cohort, and 1 historically controlled interventional study designs) involving 69,958 participants were included. The most studied interventions were formal HCV teaching (n = 12), community outreach (n = 6), and coupling screening/testing with existing programs (n = 3). Ninety-two percent (14/15) of interventions were concluded to be successful, and 71% (10/14) of those were concluded to be feasible and/or cost-effective. CONCLUSIONS: Interventions that aim to improve HCV education and accessibility to screening/treatment can substantially reduce barriers to care in South Asian communities. Further research, of higher quality RCT evidence, is needed to study the long-term reduction in HCV prevalence from these proposed interventions, and their associated feasibility profiles.

Artificial Intelligence and Surgical Education: A Systematic Scoping Review of Interventions.

OBJECTIVE: To synthesize peer-reviewed evidence related to the use of artificial intelligence (AI) in surgical education DESIGN: We conducted and reported a scoping review according to the standards outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis with extension for Scoping Reviews guideline and the fourth edition of the Joanna Briggs Institute Reviewer's Manual. We systematically searched eight interdisciplinary databases including MEDLINE-Ovid, ERIC, EMBASE, CINAHL, Web of Science: Core Collection, Compendex, Scopus, and IEEE Xplore. Databases were searched from inception until the date of search on April 13, 2021. SETTING/PARTICIPANTS: We only examined original, peer-reviewed interventional studies that self-described as AI interventions, focused on medical education, and were relevant to surgical trainees (defined as medical or dental students, postgraduate residents, or surgical fellows) within the title and abstract (see Table 2). Animal, cadaveric, and in vivo studies were not eligible for inclusion. RESULTS: After systematically searching eight databases and 4255 citations, our scoping review identified 49 studies relevant to artificial intelligence in surgical education. We found diverse interventions related to the evaluation of surgical competency, personalization of surgical education, and improvement of surgical education materials across surgical specialties. Many studies used existing surgical education materials, such as the Objective Structured Assessment of Technical Skills framework or the JHU-ISI Gesture and Skill Assessment Working Set database. Though most studies did not provide outcomes related to the implementation in medical schools (such as cost-effective analyses or trainee feedback), there are numerous promising interventions. In particular, many studies noted high accuracy in the objective characterization of surgical skill sets. These interventions could be further used to identify at-risk surgical trainees or evaluate teaching methods. CONCLUSIONS: There are promising applications for AI in surgical education, particularly for the assessment of surgical competencies, though further evidence is needed regarding implementation and applicability.