Addressing the Shortage of Academic Nurse Educators: Recommendations for Educational Institutions Based on Nominal Group Technique Research.

AIM: The purpose of this qualitative study was twofold: 1) explore factors contributing to the shortage of academic nurse educators (ANEs) and 2) identify opportunities to address these factors from the perspectives of nursing education institutions. BACKGROUND: The nurse faculty shortage is a major national concern, with inadequate recruitment and retention. Addressing the nursing faculty shortage is important to maintain a sustained nursing workforce. METHOD: Using a nominal group technique (NGT), a group of 45 diverse nurse educators from across the United States formed a virtual workgroup. RESULTS: Findings led to an action plan formulated to guide educational institutions with ways to decrease the ANE shortage through recruitment and retention. CONCLUSION: The evidence demonstrates the need for educational institutions to concentrate efforts on recruiting and retaining ANEs to combat the nursing shortage. The analysis offers recommendations to institutions to increase the number of qualified ANEs.

Demonstration of a compact double-reflection transmissive beam scanner operating at 1550 nm wavelength.

A compact forward-directed transmissive beam scanner operating at a wavelength of 1550 nm was constructed and characterized. The scanner consists of two wire-grid polarizers (WGPs) surrounding a 45° Faraday rotator, causing incident light to reflect once from each WGP before transmitting through the second polarizer. Scanning is achieved by tilting one of the WGPs. Measured efficiency remained above 73% over a 90° forward scan range (-45∘ to +45∘) for vertically polarized incident light. Additionally, we measured the efficiency versus beam deflection for four different incident linear polarization configurations, three of which maintained >70% efficiency for deflection angles up to -60∘.

Desirability of Outcome Ranking and Response Adjusted for Antibiotic Risk (DOOR/RADAR) Post Hoc Analysis Supports Equipoise for Antibiotic Initiation Strategies in Intensive Care Unit-Acquired Pneumonia.

Background: Pneumonia is the most common intensive care unit (ICU)-acquired infection and source of potential sepsis in ICU populations but can be difficult to diagnose in real-time. Despite limited data, rapid initiation of antibiotic agents is endorsed by society guidelines. We hypothesized that a post hoc analysis of a recent randomized pilot study would show no difference between two antibiotic initiation strategies. Patients and Methods: The recent Trial of Antibiotic Restraint in Presumed Pneumonia (TARPP) was a pragmatic cluster-randomized pilot of antibiotic initiation strategies for patients with suspected ICU-acquired pneumonia. Participating ICUs were cluster-randomized to either an immediate initiation protocol or a specimen-initiated protocol where a gram stain was required for initiation of antibiotics. Patients in the study were divided into one of seven mutually exclusive outcome rankings (desirability of outcome ranking; DOOR): (1) Survival, No Pneumonia, No adverse events; (2) Survival, Pneumonia, No adverse events; (3) Survival, No Pneumonia, ventilator-free-alive days ≤14; (4) Survival, Pneumonia, ventilator-free-alive days ≤14; (5) Survival, No Pneumonia, Subsequent episode of suspected pneumonia; (6) Survival, Pneumonia, Subsequent episode of suspected pneumonia; and (7) Death. These rankings were further refined using the duration of antibiotics prescribed for pneumonia (response adjusted for antibiotic risk; RADAR). Results: There were 186 patients enrolled in the study. After applying the DOOR analysis, a randomly selected patient was equally likely to have a better outcome in specimen-initiated arm as in the immediate initiation arm (DOOR probability: 50.8%; 95% confidence interval [CI], 42.7%-58.9%). Outcome probabilities were similar after applying the RADAR analysis (52.5%; 95% CI, 44.2%-60.6%; p = 0.31). Conclusions: We found that patients for whom antibiotic agents were withheld until there was objective evidence (specimen-initiated group) had similar outcome rankings to patients for whom antibiotic agents were started immediately. This supports the findings of the TARPP pilot trial and provides further evidence for equipoise between these two treatment strategies.

Interactive multidisciplinary pilot workshop to improve medical student perception of and interest in breast surgical oncology.

BACKGROUND: Exposure to breast surgical oncology (BSO) and the multidisciplinary management of patients with breast cancer is limited in medical school. The purpose of this study was to assess changes in student perceptions of BSO as a career following an interactive multidisciplinary workshop. METHODS: Pre-clinical medical students participated in a multidisciplinary, hands-on workshop, composed of breast radiology (BR), breast surgical oncology (BSO) and breast plastic reconstructive surgery (B-PRS). BR presented students screening and diagnostic breast imaging followed by hands-on ultrasound-guided biopsy on phantom simulators. BSO demonstrated lumpectomy, mastectomy, sentinel lymph node biopsy, and axillary lymph node dissections while B-PRS demonstrated oncoplastic techniques and autologous flap reconstruction with cadavers. Pre-and post-workshop surveys assessed student opinions on surgery and BSO. Results were compared using Wilcoxon Signed Rank, Wilcoxon Rank Sum, and Fisher's Exact. RESULTS: The workshop was attended by twenty-four students. There was a statistically significant increase in interest in BSO from 52% to 86% after the workshop (p = 0.003). The event improved understanding of the work and lifestyle in BSO for 79% (19/24). All students (100%) expressed interest to further explore BSO. The most common attractors to a career in BSO were impacts on patients' lives (N = 23), intellectual stimulation (N = 22), and earnings (N = 20). The most reported deterrents were lack of personal time (N = 18) and stress (N = 15). CONCLUSION: An interactive, anatomically based exposure to multidisciplinary breast cancer surgery improves medical student perception and interest in BSO. Medical schools should consider incorporating similar events to foster interest in BSO and other surgical subspecialties.

Improving Pediatric Procedural Skills for EMS Clinicians: A Longitudinal Simulation-Based Curriculum with Novel, Remote, First-Person-View Video-Based Outcome Measurement.

OBJECTIVE: Emergency medical services (EMS) clinicians are expected to provide expert care to all patients, but face obstacles in maintaining skillsets required in the care of critically ill or injured children. The objectives of this study were to describe and assess the effectiveness of a pediatric-focused, simulation-based, procedural training program for EMS clinicians, delivered on-site by a pediatric simulation education team. We also describe a novel, remote, asynchronous performance outcome measurement system using first-person-view video review. METHODS: This was a prospective study of simulation-based training and procedural outcomes. The study population involved EMS clinicians at three fire-based EMS agencies stratified as urban, suburban, and rural sites. The primary outcome was performance of intraosseous catheterization (IO), bag-valve-mask ventilation (BVM), and supraglottic device placement (SGD), measured across three time points. Secondary outcomes were identification of differences across EMS agencies and participant survey responses. RESULTS: We obtained video data from 122 clinicians, totaling 561 videos, with survey response rates of 89.0-91.3%. Pre-intervention scores were high: least-square means (95% confident-intervals) 9.5 (8.9, 10.2) for IO; 9.6 (9.3, 9.9) for BVM; and 11.6 (10.9, 12.2) for SGD. There was significant improvement post-intervention: 11.5 (10.7, 12.3) for IO; 11.0 (10.7, 11.4) for BVM; and 13.6 (12.8, 14.4) for SGD. Improvement was maintained at follow-up after a median of 9.5 months: 10.5 (9.8, 11.2) for IO; 10.2 (9.9, 10.6) for BVM; and 12.4 (11.7, 13.1) for SGD. There were no statistical differences between sites. Of survey respondents, half had not cared for a critically ill or injured child in at least a year, the vast majority had not had hands-on pediatric training in over 6 months, and the majority felt that training should occur at least every 6 months. CONCLUSIONS: Our pediatric-focused, simulation-based procedural training program was associated with improvement and maintenance of high-baseline procedural performance for EMS clinicians over the study period. Findings were consistent across sites. Remote assessment was feasible. Participant surveys emphasized a desire for more pediatric-focused training and highlighted the low frequency of clinical exposure to procedures potentially needed in the care of critically ill or injured pediatric patients.

Evaluation of learning curve with Indocyanine Green (IcG) versus blue dye for sentinel lymph node biopsy in breast cancer.

BACKGROUND: Indocyanine green (IcG) is an alternative to isosulfan blue (IB) for sentinel lymph node (SLN) mapping in breast cancer (BC). IcG carries improved cost and safety, but oncologic data upon implementation in practice is limited. We evaluated the learning curve defined as oncologic yield and operative (OR) time for IcG in SLN mapping in BC. METHODS: Retrospective review of patients >18 years with cTis-2 cN0 BC undergoing surgery first with SLN biopsy using IB or IcG. Analysis compared IB versus IcG across three time cohorts. RESULTS: Of 278 patients, 77 received IB and 201 received IcG. OR time was longer for IcG (p â€‹= â€‹0.022). There was no difference in oncologic yield between groups (p â€‹= â€‹0.35, p â€‹= â€‹0.61). CONCLUSIONS: Surgeons may be able to safely transition from IB to IcG for patients with early-stage breast cancer undergoing surgery first. Individuals should track their own data to confirm safety of the technique.

Patient Polypharmacy use Following a Multi-Disciplinary Dementia Care Program in a Memory Clinic: A Retrospective Cohort Study.

Introduction: Dementia increases the risk of polypharmacy. Timely detection and optimal care can stabilize or delay the progression of dementia symptoms, which may in turn reduce polypharmacy. We aimed to evaluate the change in polypharmacy use among memory clinic patients living with dementia who participated in a dementia care program compared to those who did not. We hypothesized that patients in the dementia care program would reduce their use of polypharmacy compared to those who were not in standard care. Methods: We retrospectively analyzed data extracted from electronic medical records from a university memory clinic. Data from a total of 381 patients were included in the study: 107 in the program and 274 matched patients in standard care. We used adjusted odds ratios to assess the association between enrollment in the program and polypharmacy use at follow-up (five or more concurrent medications), controlling for baseline polypharmacy use and stratified polypharmacy use by prescription and over-the-counter (OTC). Results: The two groups did not differ in the use of five or more overall and prescription medications at follow-up, controlling for the use of five or more of the respective medications at baseline and covariates. Being in the program was associated with a three-fold lower odds of using five or more OTC medications at follow-up (adjusted odds ratio = 0.30; p <0.001; 95% Confidence interval = 0.15-0.58) after controlling for using five or more OTC medications at baseline and covariates. Conclusions: Dementia care may reduce polypharmacy of OTC medications, potentially reducing risky drug-drug interactions. More research is needed to infer causality and understand how to reduce prescription medication polypharmacy.

Breast Cancer-Related Lymphedema (BCRL) and Bioimpedance Spectroscopy: Long-Term Follow-Up, Surveillance Recommendations, and Multidisciplinary Risk Factors.

BACKGROUND: Early detection and intervention for breast cancer-related lymphedema (BCRL) significantly decreases progression to persistent BCRL (pBCRL). We aimed to provide long-term follow-up on our early detection with bioimpedance spectroscopy (BIS) and early home intervention demonstrating reduced pBCRL to guide surveillance recommendations. PATIENTS AND METHODS: In total, 148 female patients with breast cancer who had axillary lymph node dissection (ALND) from November 2014 to December 2017 were analyzed. Baseline BIS measurements and postoperative follow-up occurred every 3 months for 1 year, biannual for 1 year, and then annually. An elevated BIS triggered evaluation and initiation of at-home interventions with reassessment for resolution versus persistent BCRL (pBCRL). High-risk factors and timing were analyzed. RESULTS: Mean follow-up was 55 months, and 65 (44%) patients had an abnormal BIS. Of these, 54 (82%) resolved with home intervention. The overall pBCRL rate was 8%. Average time to first abnormal BIS was 11.7 months. None of the stage 0 patients (0/34) and only 5/25 (20%) of stage 1 patients had pBCRL. All of stage 2 and stage 3 patients (7/7) had pBCRL. pBCRL correlated with number of positive nodes, percentage of positive nodes, stage of lymphedema at diagnosis, and recurring abnormal BIS measurements (p < 0.05). CONCLUSIONS: We have shown that patients undergoing ALND with early BCRL identified by BIS who performed home interventions had an 8% pBCRL rate. Patients at high risk for pBCRL should have routine surveillance starting at 9 months postoperatively to identify an opportunity for early intervention.

Assessing the Risk of Postoperative Complications for Proximal Humeral Fractures Treated by Open Reduction and Internal Fixation in Patients With Diabetes and Chronic Kidney Disease.

BACKGROUND: The prevalence of diabetes mellitus (DM) and chronic kidney disease (CKD) has markedly risen over the past three decades. Patients with DM and CKD are at increased risk of infection, immune dysfunction, as well as bone and mineral disorders. Although we know that patients with DM and CKD have these risks, we do not know how these translate to proximal humeral fracture (PHF) healing. We sought to analyze whether these established comorbidities had increased rates of complications after open reduction and internal fixation (ORIF) for PHF treatment. METHODS: Using a national insurance database, 72,365 patients with PHF managed with ORIF were identified using records from 2010 to 2022. Patients were initially split into those with DM and those without and were further stratified by the presence or absence of CKD. For our comparison baseline cohort, patients were not diagnosed with either DM or CKD. Post-ORIF complication rates were assessed looking specifically at nonunion, postoperative infection, and all-cause revision surgery. A logistic regression statistical analysis was also conducted. RESULTS: Of the 72,365 patients with PHF treated by ORIF, 41,047 were non-DM without CKD (comparison); 17,025 had DM alone (no CKD); 11,729 had DM and CKD; and 2564 had CKD alone (non-DM). Multivariate analysis indicated that patients with DM and/or CKD were at increased risk of developing nonunion (odds ratio [OR] = 1.37, 1.48, 1.23) and all-cause revision surgery (OR = 1.21, 1.11, 1.18) after ORIF for PHF compared with our comparison cohort. In addition, all patients with DM alone (non-CKD) and DM with CKD had an increased risk of postoperative infection (OR = 1.39, 1.26). CONCLUSION: The management of PHF is a controversial topic, particularly regarding the degree of intervention and optimal treatment choice. Regardless, using a pragmatic design and reviewing a national insurance database, this study provides information for patients in high-risk populations, specifically patients with DM and CKD, and may prove beneficial when selecting a patient-specific treatment plan. Additional studies are needed to assess varying stages of both DM and CKD in patients who sustain PHF treated by ORIF along with postoperative strategies to minimize complications.

Managing Post-Operative Pain in Orthopedic Patients: An International Comparison.

Introduction: Opioids play a crucial role in post-operative pain management in America, but not in some other countries. We sought to determine if a discrepancy in opioid use between the United States (U.S.) and Romania, a country that administers opioids in a conservative fashion, would show in subjective pain control differences. Methods: Between May 23, 2019, and November 23, 2019, 244 Romanian patients and 184 American patients underwent total hip arthroplasty or the surgical treatment of the following fractures: bimalleolar ankle, distal radius, femoral neck, intertrochanteric, and tibial-fibular. Opioid and non-opioid analgesic medication use and subjective pain scores during the first and second 24 hours after surgery were analyzed. Results: Subjective pain scores for the first 24 hours were higher among patients in Romania compared to the U.S. (p < 0.0001), but Romanians reported lower pain scores than U.S. patients in the second 24-hours (p < 0.0001). The quantity of opioids given to U.S. patients did not differ significantly based on sex (p = 0.4258) or age (p = 0.0975). However, females reported higher pain scores than male patients following the studied procedures (p = 0.0181). No sex-based differences in pain scores were noted among Romanian patients. Conclusions: Higher pain scores in American females, despite equivalent amounts of narcotics to their male counterparts, and the absence of a difference in Romanians suggested that the current American post-operative pain regimen may be tailored to the needs of male patients. In addition, it pointed to the impacts of gender, compared to sex, in pain experiences. Future research should look for the safest, most efficacious pain regimen suitable for all patients.

Retrospective chart review: Weightbearing CT scans and the measurement of the Lisfranc ligamentous complex.

BACKGROUND: Lisfranc Ligamentous Complex (LLC) injuries are commonly misdiagnosed due to their unreliable projection on plain films. Weightbearing CT (WBCT) scans are a relatively new imaging modality that has not yet been utilized to establish widely referenced baseline anatomic positions. METHODS: A retrospective chart review was conducted of patients who had undergone weightbearing CT of the bilateral lower extremities with one-hundred and twelve being included (56 patients). Measurements of the Lisfranc joint were collected by two independent reviewers. Uninjured symmetric anatomy was used to describe a baseline for normal anatomic variation and to evaluate for sex-based or age-related differences. These measurements were then compared against the injured side. RESULTS: In patients without Lisfranc injury, the 1st metatarsal base to 2nd metatarsal base distance (Base M1-M2) was 2.7 + /- 0.7 mm; 2nd metatarsal base to medial cuneiform (M2-C1) was 3.7 + /- 0.7 mm; intercuneiform distance was 1.2 + /- 0.3 mm; and sagittal descent 12.2 + /- 5.4 mm. Patients with injury to LLC had a larger M1-M2 base distance (Δ = 0.5903, p < 0.0001) and M2-C1 interval (Δ = 1.8008, p < 0.0001) compared to uninjured side. Males had significantly higher M2-C1 (p = 0.0031), intercuneiform distance (p = 0.0039), and sagittal descent (p = 0.0008) compared to female patients. No significant differences were found between left versus right side in any of the measurements. Intercuneiform distance (p = 0.0039) was found to significantly decrease as age increased, while sagittal descent significantly increased with increased age (p = 0.0066). CONCLUSION: Weightbearing CT has high utility in identification of Lisfranc injuries particularly when comparing injured and uninjured sides, which may be its greatest utility in defining injuries. This is evident in the excellent diagnostic ability of the M2-C1 measurement. By defining baseline anatomic measurements for Lisfranc complex parameters in our patient population, we provide normal parameters for comparison when evaluating potential subtle injuries. LEVEL OF EVIDENCE: III.

Sex-Based Differences in Outcomes After Hip Arthroscopic Surgery for Femoroacetabular Impingement: A Systematic Review.

Background: While sex-based differences in outcomes after hip arthroscopic surgery for femoroacetabular impingement syndrome (FAIS) are often recorded, no studies have been dedicated to analyzing the literature as a whole. Purpose: To investigate whether sex is a predictor of outcomes in studies evaluating hip arthroscopic surgery for FAIS. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We searched the PubMed, Embase, Cochrane, Ovid, and PubMed Central databases for English-language studies that evaluated sex-specific outcomes in human populations. The search terms used were as follows: ("Hip Arthroscopy") AND ("Femoroacetabular Impingement" OR "FAI") AND ("Sex" OR "Gender" OR "Male" OR "Female"). Studies with evidence levels 2 through 4 were included. The studies were then screened, followed by data extraction. Modified Harris Hip Score (mHHS) outcomes and return-to-sport (RTS) rates were recorded. These were analyzed using random-effects meta-analysis. Heterogeneity was calculated using the I 2 statistic. Results: Of 256 full-text articles screened, 48 articles were included in this analysis; of these, 14 studies (29%) concluded that female sex was a negative predictor of postoperative outcomes, while 6 studies (13%) found female sex to be positive predictor. The remaining 28 studies (58%) found no sex-based differences in postoperative outcomes. Of 7 studies (416 male and 519 female) included in the mHHS analysis, 2 studies concluded that male patients had significantly higher postoperative mHHS scores. Of 6 studies (502 male and 396 female) included in the RTS analysis, 1 study concluded that male patients had a significantly higher RTS rate. Conclusion: Almost one-third of the included studies determined that female sex was a negative predictor of postoperative outcomes, 13% found female sex to be a positive predictor, and 58% found no sex-based differences. Our study illustrates an insufficiency of high-level evidence supporting sex-specific differences in outcomes after hip arthroscopic surgery, but findings indicated that the postoperative mHHS score and RTS rate may be influenced by sex.

Emergency Action Planning in Kasas High Schools.

Introduction: Current evidence showed a variable rate of emergency action plan (EAP) implementation and a low rate of compliance to EAP guidelines in United States secondary schools. Compliance to EAP recommendations in Kansas high schools is not known. The purpose of this study was to identify the emergency preparedness of high school athletics in the state of Kansas and identify prevailing characteristics of schools that correlate with decreased compliance of an EAP. Methods: Athletic directors for high schools in the state of Kansas were asked to participate in a web-based questionnaire that was emailed to each athletic director. The questionnaire identified demographics of the study population, EAP implementation rates, compliance to national EAP guidelines, access to certified medical personnel, and training received by athletics personnel. Descriptive statistics were then compiled and reported. Results: The response rate for the survey was 96% (341/355). A total of 94.1% (320/340) of schools have an EAP, 81.4% (276/339) of schools have an automated external defibrillator (AED) at all athletic venues, and 51.8% (176/340) of schools had an athletic trainer (AT) on staff. Urban schools were significantly more likely than rural schools to have an AT on staff (OR = 11.10, 95% CI = [6.42, 19.18], p < 0.0001), have an EAP (OR = 3.69, 95% CI = [1.05, 13.02], p = 0.0303), require additional training for coaches (OR = 2.69, 95% CI = [1.42, 5.08], p = 0.0017), and have an AED on-site for some events (OR = 2.18, 95% CI = [1.24, 3.81], p = 0.0057). Conclusions: Most Kansas high schools have an EAP in place and have at least one AED. Emergency planning should be improved through venue specific EAPs, access to early defibrillation, and additional training. Rural and lower division schools had less AT staffing and consequently were impacted more significantly than urban and higher division schools by these factors. These factors should be taken into account in future improvement strategies.

A Measure of Burnout in Current NCAA Student-Athletes.

Introduction: The prevalence of athletes who specialize in sports has increased in recent years. Substantial literature on youth sports has linked early sport specialization to negative consequences, such as burnout and injury. However, empirical evidence comparing rates of burnout and specialization in NCAA athletes is limited. The purpose of this study was to survey current NCAA Division I student-athletes to compare levels of burnout to sex, year of NCAA eligibility, and age at the beginning of sport specialization. Methods: A self-reported survey was distributed to student-athletes at two NCAA Division I institutions, which included demographics, sport specialization history, injury history, and the Athlete Burnout Questionnaire. Results from the three measures of the Athlete Burnout Questionnaire (reduced sense of accomplishment, exhaustion, sport devaluation) were compared to sex, year of NCAA eligibility, age of beginning sport specialization, and injury history. Results: A total of 267 athletes (95 males and 172 females) completed the survey. Of those, 156 (58.4%) were in their first or second year of NCAA eligibility, and 111 (41.6%) were in their third, fourth, or fifth year. Of the total, 121 (46.4%) reported specializing before the age of 15, and 140 (53.6%) specialized at age 16 or older. Females reported significantly higher levels of exhaustion than males (Difference of means (M) = 0.43, 95% confidence interval (CI) = [0.20, 0.66], p < 0.01). Athletes in their third, fourth, or fifth year of eligibility reported significantly higher levels of sport devaluation (M = 0.27, 95% CI = [0.05, 0.48], p < 0.05) than athletes in their first or second year. Athletes who specialized before age 15 did not report significantly higher levels of burnout than athletes who specialized at age 16 or later. In total, 203 athletes (77.2%) reported experiencing any injury. Athletes who reported a history of experiencing any injury demonstrated significantly higher feelings of reduced sense of accomplishment than athletes with no injury history (Difference of means (M) = 0.24, 95% confidence interval (CI) = [0.03, 0.45], p < 0.05). Conclusions: Athletes were more likely to experience elevated levels of burnout if they reported female sex, older NCAA eligibility, or a past injury history. However, athletes were not more likely to experience increased burnout based on age of beginning specialization. The results demonstrated a need to address burnout in athletes following injury and to be aware that females and older athletes are more prone to burnout.

Rural-Urban Disparities in Health Access Factors Over Time: Implications for Cancer Prevention and Health Equity in the Midwest.

Purpose: Population-level environmental and socioeconomic factors may influence cancer burden within communities, particularly in rural and urban areas that may be differentially impacted by factors related to health care access. Methods: The University of Kansas (KU) Cancer Center serves a geographically large diverse region with 75% of its 123 counties classified as rural. Using County Health Rankings data and joinpoint regression, we examined trends in four factors related to the socioeconomic environment and health care access from 2009 to 2017 in rural and urban counties across the KU Cancer Center catchment area. Findings: The adult health uninsurance rate declined significantly in rural and urban counties across the catchment area (rural annual percent change [APC]=-5.96; 95% CI=[-7.71 to -4.17]; urban APC=-5.72; 95% CI=[-8.03 to -3.35]). Childhood poverty significantly decreased in rural counties over time (APC=-2.94; 95% CI=[-4.52 to -1.33]); in contrast, urban childhood poverty rates did not significantly change before 2012 (APC=3.68; 95% CI=[-15.12 to 26.65]), after which rates declined (APC=-5.89; 95% CI=[-10.01 to -1.58]). The number of primary care providers increased slightly but significantly in both rural and urban counties (APC=0.54; 95% CI=[0.28 to 0.80]), although urban counties had more primary care providers than rural areas (76.1 per 100K population vs. 57.1 per 100K population, respectively; p=0.009). Unemployment declined significantly faster in urban counties (APC=-10.33; 95% CI=[-12.16 to -8.47]) compared with rural counties (APC=-6.71; 95% CI=[-8.22 to -5.18]) (p=0.02). Conclusion: Our findings reveal potential disparities in systemic factors that may contribute to differences in cancer prevention, care, and survivorship in rural and urban regions.

Males and Females Exhibit Comparable Outcomes Following Treatment of Osteochondritis Dissecans Lesions of the Knee: A Systematic Review.

PURPOSE: The purpose of this study was to evaluate the impact of patient sex on outcomes after treatment of osteochondritis dissecans (OCD) lesions of the knee through a systematic review of current evidence. METHODS: This review was conducted according to the PRISMA guidelines using the PubMed, PubMed Central, Embase, Ovid Medline, Cochrane Libraries, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Relevant outcomes included functional (e.g., International Knee Documentation Committee and Subjective Knee Evaluation, Lysholm Knee Score) and clinical outcomes (e.g., symptom/pain resolution, reoperation rates) for males and females after operative or nonoperative treatment of knee OCD lesions. RESULTS: Ten articles with a total of 691 (73%) males and 260 (27%) females were included. Mean age ranged from 11.3 ± 2.1 years to 34.5 ± 10.3 years, and follow-up ranged from 6 months to 16.3 years. In four studies reporting functional outcomes, no significant differences were found between males and females in any metric assessed (all P > .05). Seven studies reported clinical outcomes after treatment of knee OCD lesions. One study determined males were more likely to have a successful nonoperative outcome than females (OR: 1.85, 95% CI: 1.00-3.40). Another study found males had a lower risk of developing symptomatic knee pain following operative or nonoperative treatment at a mean 14-year follow-up (HR: 0.24; 95% CI: 0.07-0.81). The remaining 5 studies reported statistically comparable clinical outcomes between males and females (all P > .05). CONCLUSION: The present systematic review found mostly comparable clinical and functional outcomes between males and females following treatment of knee OCD lesions. Despite sex-related differences in the prevalence of these lesions and limited evidence of differences in clinical outcomes, these data suggest that sex does not independently predict outcomes after treatment. LEVEL OF EVIDENCE: III, systematic review of Level II and III studies.

Evaluating factors affecting length of hospital stay in patients with metastatic bone tumors.

BACKGROUND: Specific medical conditions known to increase LOS following orthopedic surgery including congestive heart failure, diabetes mellitus and COPD. It is also known that patient demographics such as increasing age and non-white race can negatively affect orthopedic surgical outcomes However, there is a lack of research examining the effect of these variables on patients with metastatic bone disease regarding length of hospital stay and ultimately economic burden following surgery. The aim of this study is to identify factors affecting LOS in patients following surgery for bone metastasis. METHODS: A retrospective chart review was used to extract data from 93 patients with an underlying diagnosis of bony metastatic cancer who underwent an orthopedic surgical procedure. Data collected included: length of hospital stay, demographic information (age, sex, race, BMI, smoking status), complications (infection, DVT, PE, fractures), pre-operative lab values (WBC, Albumin, Creatinine, HbA1c), primary cancer type, and surgical procedure measures to understand which factors affected LOS. RESULTS: Increased LOS in this specific patient population was found to be associated with pre-existing diabetes (P = 0.005), obesity (P = 0.025), multiple disease sites (P = 0.042), or disease at the femur (P = 0.035). Patients had a decreased LOS when undergoing a prophylactic procedure (3.53 days vs 5.51 days for non-prophylactic procedure). DISCUSSION: These findings allow providers to better communicate expectations regarding the duration of admission and allows for a better estimation of cost burden for patients and health systems. The present study demonstrates increased LOS in patients undergoing orthopedic procedures for metastatic bone disease who had pre-existing diabetes, obesity, multiple disease sites, disease in the femur, or surgery for a pathologic fracture (as opposed to a prophylactic procedure). Understanding the factors affecting LOS in this patient population can optimize preoperative care, improve communication between the patient and provider, and ultimately decrease financial burden.

Sex-specific differences in outcomes after anterior shoulder surgical stabilization: a meta-analysis and systematic review of literature.

BACKGROUND: Anterior shoulder instability frequently occurs in young, physically active individuals and may be treated with surgical stabilization. Previous studies have shown that males more often require surgical management for anterior shoulder instability and may have a higher frequency of recurrent instability episodes after surgical management, but females have been found to have increased incidence of apprehension after surgical stabilization. The purpose of this study is to review the literature and assess anterior shoulder surgical stabilization postoperative outcomes between males and females to identify and describe sex-based differences. METHODS: A systematic search of electronic databases was conducted to identify level I-IV clinical studies on anterior shoulder instability published between 1960 and August 2020. We included studies that evaluated sex-specific outcomes in patients who underwent anterior shoulder instability procedures. A meta-analysis of the data was performed to analyze sex-specific outcomes. RESULTS: Thirty studies (2.1%) met inclusion criteria, representing 9829 patients. Of the studies that reported the number of male and female patients, 74% were male and 26% were female. Twenty-six studies used Bankart repair alone, two used open Latarjet procedure alone, and two had a Bankart repair group and Latarjet procedure group. Instability recurrence, return to sport, and apprehension were included in the meta-analysis. Our meta-analysis demonstrated a significantly higher rate of instability recurrence for males than for females who underwent arthroscopic Bankart repair (risk ratio [RR] = 1.25; 95% confidence interval [CI] = 1.03, 1.52; P = .0239). We did not identify a significant difference between males and females in rates of apprehension (RR = 0.68; 95% CI = 0.37, 1.27; P = .2300) or return to sport (RR = 0.98; 95% CI = 0.81, 1.18; I2 = 0%; P = .8110) for arthroscopic Bankart repair or open Latarjet procedure. CONCLUSION: For patients who underwent arthroscopic Bankart repair for anterior shoulder stabilization, recurrent rates of instability were significantly higher for males than for females. When open Bankart and Latarjet procedures were included, there was no difference. No difference was seen between males and females after arthroscopic Bankart repair or open Latarjet procedures with regard to return to sport or apprehension.

Sex-Specific Outcomes After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis.

BACKGROUND: Despite the significant difference between men and women in incidence of anterior cruciate ligament (ACL) injuries, there is a paucity of consistent information on the influence of patient sex on outcomes after ACL reconstruction. A previous meta-analysis has demonstrated that female patients have worse outcomes with regard to laxity, revision rate, Lysholm score, and Tegner activity score and are less likely to return to sports (RTS). PURPOSE: To conduct a systematic review and meta-analysis to evaluate and compare sex-specific outcomes after ACL reconstruction. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review was performed using PubMed, PubMed Central, Embase, OVID, and Cochrane databases per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The following search terms were used: "anterior cruciate ligament reconstruction" OR "ACL reconstruction" OR "anterior cruciate ligament" OR "ACL" AND "gender" OR "sex" OR "male" OR "female" AND "outcome" AND "2015-Present" to gather all relevant articles between 2015 and 2020. A risk-of-bias assessment and quality assessment was conducted on included studies. RESULTS: Of 9594 studies initially identified, 20 studies with 35,935 male and 21,455 female patients were included for analysis. The 7 studies reporting International Knee Documentation Committee (IKDC) scores showed that male patients had statistically significantly higher postoperative scores (mean difference, 3.02 [95% CI, 1.19-4.84]; P< .01; I 2 = 66%), and 7 studies that reported the rate of ACL revision showed there was no significant difference between male and female patients (odds ratio, 0.85 [95% CI, 0.45-1.60]; P = .61; I 2 = 94%). The 7 studies that reported rates of rerupture showed that males were significantly more likely than females to have a graft rerupture (odds ratio, 1.35 [95% CI, 1.22-1.50]; P < .01; I 2 = 0%). Male patients reported a higher RTS rate than did their female counterparts (59.82% compared with 42.89%); however, no formal statistical analysis could be done because of the variability in reporting techniques. CONCLUSION: Male and female patients with ACL injuries demonstrated similar outcomes regarding their rates of revision; however, male patients were found to have statistically significantly higher postoperative IKDC scores but at the same time higher rerupture rates. Our findings suggest that sex-based differences in outcomes after ACL reconstruction vary based on which metric is used. These results must be considered when counseling patients with ACL injuries.