The role of orthopaedic trainees during the COVID-19 pandemic and impact on post-graduate orthopaedic education: a four-nation survey of over 100 orthopaedic trainees.

AIMS: The COVID-19 pandemic has had a significant impact on the provision of orthopaedic care across the UK. During the pandemic orthopaedic specialist registrars were redeployed to "frontline" specialties occupying non-surgical roles. The impact of the COVID-19 pandemic on orthopaedic training in the UK is unknown. This paper sought to examine the role of orthopaedic trainees during the COVID-19 and the impact of COVID-19 pandemic on postgraduate orthopaedic education. METHODS: A 42-point questionnaire was designed, validated, and disseminated via e-mail and an instant-messaging platform. RESULTS: A total of 101 orthopaedic trainees, representing the four nations (Wales, England, Scotland, and Northern Ireland), completed the questionnaire. Overall, 23.1% (23/101) of trainees were redeployed to non-surgical roles. Of these, 73% (17/23) were redeployed to intensive treatment units (ITUs), 13% (3/23) to A/E, and 13%(3/23%) to general medicine. Of the trainees redeployed to ITU 100%, (17/17) received formal induction. Non-deployed or returning trainees had a significant reduction in sessions. In total, 42.9% (42/101) % of trainees were not timetabled into fracture clinic, 53% (53/101) of trainees had one allocated theatre list per week, and 63.8%(64/101) of trainees did not feel they obtained enough experience in the attached subspecialty and preferred repeating this. Overall, 93% (93/101) of respondents attended at least one weekly online webinar, with 79% (79/101) of trainees rating these as useful or very useful, while 95% (95/101) trainees attended online deanery teaching which was rated as more useful than online webinars (p = 0.005). CONCLUSION: Orthopaedic specialist trainees occupied an important role during the COVID-19 pandemic. COVID-19 has had a significant impact on orthopaedic training. It is imperative this is properly understood to ensure orthopaedic specialist trainees achieve competencies set out in the training curriculum.Cite this article: Bone Joint Open 2020;1-11:676-682.

Trauma surgery at a designated COVID-19-free site during the pandemic: a safe model and a possible way to restart routine elective surgery.

AIMS: Elective operating was halted during the COVID-19 pandemic to increase the capacity to provide care to an unprecedented volume of critically unwell patients. During the pandemic, the orthopaedic department at the Aneurin Bevan University Health Board restructured the trauma service, relocating semi-urgent ambulatory trauma operating to the isolated clean elective centre (St. Woolos' Hospital) from the main hospital receiving COVID-19 patients (Royal Gwent Hospital). This study presents our experience of providing semi-urgent trauma care in a COVID-19-free surgical unit as a safe way to treat trauma patients during the pandemic and a potential model for restarting an elective orthopaedic service. METHODS: All patients undergoing surgery during the COVID-19 pandemic at the orthopaedic surgical unit (OSU) in St. Woolos' Hospital from 23 March 2020 to 24 April 2020 were included. All patients that were operated on had a telephone follow-up two weeks after surgery to assess if they had experienced COVID-19 symptoms or had been tested for COVID-19. The nature of admission, operative details, and patient demographics were obtained from the health board's electronic record. Staff were assessed for sickness, self-isolation, and COVID-19 status. RESULTS: A total of 58 surgical procedures were undertaken at the OSU during the study period; 93% (n = 54) of patients completed the telephone follow-up. Open reduction and internal fixation of ankle and wrist fractures were the most common procedures. None of the patients nor members of their households had developed symptoms suggestive of COVID-19 or required testing. No staff members reported sick days or were advised by occupational health to undergo viral testing. CONCLUSION: This study provides optimism that orthopaedic patients planned for surgery can be protected from COVID-19 nosocomial transmission at separate COVID-19-free sites.Cite this article: Bone Joint Open 2020;1-6:302-308.

Stress and Anxiety Management During the COVID-19 Pandemic (Lessons Learnt from a Cohort of Orthopaedic Registrars Redeployed to ITU).

BACKGROUND: Working during the coronavirus pandemic has had a significant impact on health care workers. A group of orthopaedic trainees at Royal Gwent Hospital, UK, were redeployed to intensive therapy unit for four weeks during COVID-19 pandemic. This study reviews our experience; focusing on causes of stress and anxiety, and how they were managed. The lessons learnt could be used as a framework for pre-emptive me-asures during future challenges. MATERIAL AND METHODS: Orthopaedic registrars were divided into two groups. Seven trainees (Redeployed group) moved to ITU for four weeks to support the critical care team. The other group (Retained group) of eight registrars continued to cover orthopaedic rota. A survey was done for anxiety levels comparing the two groups at three time points during these four weeks. RESULTS: Anxiety and stress in the ITU-redeployed group was comparatively less than the continuing group as time progressed during the redeployment. CONCLUSIONS: 1. The disruptive impact of the COVID-19 pandemic has been a source of massive stress and an-xiety for health care workers. 2. Our experience shows that stress is controllable with the correct strategies. 3. The main points are early identification of vulnerable groups, proper induction, active involvement, adequate explanation, appreciation, good communication, and available psychological support whenever needed. 4. These are essential to maintain a resilient workforce against upcoming waves of COVID-19.

Diabetes and Depression Care: A Randomized Controlled Pilot Trial.

OBJECTIVE: We examined the comparative effectiveness of an integrated intervention for Type 2 diabetes mellitus (T2DM) and depression by employing patient prioritized planning (PPP) to incorporate patients' financial, social, and emotional needs versus an integrated intervention alone. METHODS: A randomized controlled pilot trial randomly assigned 78 patients prescribed pharmacotherapy for T2DM in primary care to an integrated intervention for T2DM and depression employing PPP to incorporate patients' financial, social, and emotional needs (enhanced intervention) versus an integrated intervention alone (basic intervention). Hemoglobin A1C (HbA1C) assays measured glycemic control and the Center for Epidemiologic Studies Depression Scale (CES-D) assessed depression. RESULTS: Patients in the enhanced intervention had a significantly greater mean change in HbA1C from baseline in comparison with the basic intervention at 12 weeks (enhanced intervention -0.63 vs basic intervention 0.15; p = .027). Patients in the enhanced intervention also had a significantly greater mean change in CES-D from baseline in comparison with patients in the basic intervention group at 12 weeks (enhanced intervention -3.75 vs basic intervention 0.93; p = .041). CONCLUSIONS: Our pilot trial results indicate that an integrated care intervention employing PPP to incorporate financial, social and emotional needs for primary care patients with T2DM and depression may be effective.

A double-blind, placebo-controlled study of the impact of galantamine on anterograde memory impairment during electroconvulsive therapy.

BACKGROUND: Electroconvulsive therapy (ECT) continues to be an effective treatment option for patients who fail to respond to pharmacological interventions, are unable to tolerate medications, and show a suboptimal response to behavioral and psychotherapeutic treatments. However, risks for cognitive impairment may contribute to some patients' refusal of ECT. METHODS: The present study examined galantamine as a pharmacological intervention to reduce cognitive adverse effects from ECT. Thirty-nine inpatients diagnosed with major depressive disorder; bipolar disorder, depressed type; or schizoaffective disorder, depressed type and admitted for ECT were randomized to galantamine or placebo. Study drugs were initiated 24 to 48 hours before starting ECT and continued throughout the course of ECT. A neuropsychological test battery was administered at baseline and 24 to 48 hours after completing a course of ECT treatments. Depression severity was monitored using the 17-item Hamilton Rating Scale for Depression and Clinical Global Impression Scale at baseline, weekly, and end point. Self-rated adverse effects were monitored weekly. RESULTS: Thirty participants (12 patients in the galantamine group, 18 patients in the placebo group) had both pretreatment and posttreatment neuropsychological ratings. Those in the galantamine group scored significantly higher at discharge for delayed memory (t28 = 2.44, P < 0.05). Hierarchical regressions examined if treatment condition predicted changes in delayed memory scores from baseline to discharge. Inclusion of the treatment condition in the final model made a significant incremental improvement in prediction (ΔR = 0.12, F1,27 change = 4.65, P < 0.05; ß = 0.37, t = 2.16, P < 0.05). Galantamine was well tolerated with no clinically significant bradycardia or prolonged paralysis when administered with ECT. CONCLUSIONS: Galantamine may be protective against impairment in retention of new learning. Galantamine exhibited minimal adverse effects and was safe when administered during ECT. The present findings require replication by future researchers using larger samples before broad conclusions can be drawn.

An open study of aripiprazole and escitalopram for psychotic major depressive disorder.

OBJECTIVE: This 7-week trial assessed the efficacy and tolerability of aripiprazole combined with escitalopram in the acute treatment of major depressive disorder, with psychotic features (MD-Psy). METHODS: Sixteen male and female patients with a Diagnostic Statistical Manual of Mental Disorders, Fourth Edition, diagnosis of MD-Psy were recruited for this study from September 13, 2004 to August 9, 2006. Escitalopram and aripiprazole were flexibly dosed for 7 weeks, with maximum dosages of 20 and 30 mg/d, respectively. The 17-item Hamilton Rating Scale for Depression (HAM-D-17) and Structured Clinical Interview for DSM-IV psychosis module were used to measure depression and psychosis responses. The Barnes Akathisia Scale and the Simpson Angus Scale were used to assess for akathisia and extrapyramidal symptoms. RESULTS: Thirteen of the 16 subjects completed the study. The MD-Psy response rate (50% or greater drop in HAM-D-17 and no psychosis) (intent-to-treat, last observation carried forward) was 62.5%, and the MD-Psy remission rate (HAM-D-17, <8, and no psychosis) (intent-to-treat, last observation carried forward) was 50.0%. Ten of the 16 subjects developed akathisia; however, 9 of the 10 subjects had resolution or partial resolution of akathisia with dose adjustment or treatment with propranolol. CONCLUSIONS: The combination of escitalopram and aripiprazole seems to be an effective and safe treatment for MD-Psy.

Association of a polymorphism near CREB1 with differential aversion processing in the insula of healthy participants.

CONTEXT: Previous functional neuroimaging studies have identified a network of brain regions that process aversive stimuli, including anger. A polymorphism near the cyclic adenosine monophosphate response element binding protein gene (CREB1) has recently been associated with greater self-reported effort at anger control as well as risk for antidepressant treatment-emergent suicidality in men with major depressive disorder, but its functional effects have not been studied. OBJECTIVE: To determine whether this genetic variant is associated with altered brain processing of and behavioral avoidance responses to angry facial expressions. DESIGN AND PARTICIPANTS: A total of 28 white participants (mean age, 29.2 years; 13 women) were screened using the Structured Clinical Interview for DSM-IV to exclude any lifetime Axis I psychiatric disorder and were genotyped for rs4675690, a single-nucleotide polymorphism near CREB1. MAIN OUTCOME MEASURES: Blood oxygenation level-dependent signal by functional magnetic resonance imaging in the amygdala, insula, anterior cingulate, and orbitofrontal cortex during passive viewing of photographs of faces with emotional expressions. To measure approach and avoidance responses to anger, an off-line key-press task that traded effort for viewing time assessed valuation of angry faces compared with other expressions. RESULTS: The CREB1-linked single-nucleotide polymorphism was associated with significant differential activation in an extended neural network responding to angry and other facial expressions. The CREB1-associated insular activation was coincident with activation associated with behavioral avoidance of angry faces. CONCLUSIONS: A polymorphism near CREB1 is associated with responsiveness to angry faces in a brain network implicated in processing aversion. Coincident activation in the left insula is further associated with behavioral avoidance of these stimuli.