Regional anaesthesia training in the UK - a national survey.

Background: Adequate training of anaesthetists in regional anaesthesia is important to ensure optimal patient access to regional anaesthesia. Methods: We undertook a national survey of UK trainee anaesthetists and Royal College of Anaesthetists (RCoA) tutors to assess experiences of training in regional anaesthesia. We performed descriptive statistics for baseline characteristics, and logistic regression of training indices and tutor confidence that their hospital could provide regional anaesthesia training at all three stages of the RCoA 2021 curriculum. Results: A total of 492 trainees (19.2%) and 114 tutors (45.2%) completed the survey. Trainees were less likely to have received training in chest/abdominal wall compared with upper/lower limb blocks {erector spinae vs femoral block (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.16-0.39), P<0.001}, or achieved >20 chest/abdominal wall blocks by Stage 3 of training (chest vs lower limb block [OR 0.09, 95% CI 0.05-0.15, P<0.001]. There was a strong association between training received, number of blocks performed (>20 vs 0-5 blocks), and self-reported ability to perform blocks independently, OR 20.9 (95% CI 9.38-53.2). 24/182 (13%) and 10/182 (5.5%) of trainees had performed ≥50 non-obstetric lumbar and thoracic epidurals, respectively, by Stage 3 training. There was a positive association between having a lead clinician for regional anaesthesia, particularly those with paid sessions, and reported confidence to provide regional anaesthesia training at all stages of the curriculum (Stage 3 OR 7.27 [95% CI 2.64-22.0]). Conclusion: Our results confirm the importance of clinical experience and access to training in regional anaesthesia, and support the introduction of departmental regional anaesthesia leads to improve equity and quality in training opportunities.

SLAP Tears: Treatment Algorithm.

SLAP lesions can be significant pain generators in the shoulder. These injuries are the most common shoulder injury in overhead athletes, as repetitive overhead motion is the most common etiology of SLAP lesions. These lesions present a diagnostic and treatment challenge to patients and physicians. Factors to consider when discussing treatment options for SLAP lesions include age, type of sports activity, level of sports participation, and degree of symptoms. Nonoperative management is the first-line treatment for most young, active patients without history of trauma, mechanical symptoms, and/or demand for overhead activities. These conservative measures include rest, avoidance of aggravating factors, injections, and physical therapy focusing on correcting scapular dyskinesis, restoring range of motion and strength, and evaluating the biomechanical throwing motion. It has been reported that 40% of professional baseball players can successfully return to play after rehabilitation alone. Alternatively, operative treatment is reserved for failure of nonoperative treatment and those with persistent symptoms that prevent individuals from participating in sports activities or activities of daily living. The two most common operative treatment options include arthroscopic repair versus biceps tenodesis. Arthroscopic repair can be considered in younger athletes (<30 years old) and elite athletes who are involved in overhead sports (baseball, tennis, volleyball) and consists of repairing the labral anchor back to the superior glenoid rim with knotless anchor repair techniques. Alternatively, biceps tenodesis is the first-line treatment option for failed SLAP repairs, and as an index procedure, traditionally has been reserved for middle-aged individuals (>30 years old), patients receiving workers' compensation, nonoverhead athletes, or in those with concomitant rotator cuff tears. However, due to a relatively high failure rate of SLAP repairs, biceps tenodesis as an index procedure is gaining more popularity, as emerging evidence suggests encouraging functional outcomes and return-to-sport rates even in younger athletes.

Patients With Medicaid Insurance Undergoing Anterior Cruciate Ligament Reconstruction have Lower Postoperative International Knee Documentation Committee Scores and are Less Likely to Return to Sport Than Privately Insured Patients.

Purpose: To determine whether patients insured through Medicaid exhibit differences in patient-reported outcomes, return to sport rates, and reinjury and reoperation metrics after anterior cruciate ligament (ACL) reconstruction compared with patients insured with private insurance. Methods: Patients insured through Medicaid who had undergone a primary ACL reconstruction were identified and compared with a matched cohort of patients insured through private insurance with the same age and sex. Patients were contacted via telephone and emailed a questionnaire containing the International Knee Documentation Committee (IKDC) score, return to sport questions, and reinjury and reoperation metrics. Physical therapy (PT) notes were also reviewed to determine number of PT visits attended and distance from patients' home address to PT facility. Results: A total of 26 patients insured through Medicaid and 25 insured through private insurance were enrolled in this study. The 2 groups demonstrated no statistically significant differences in age, body mass index, or sex. There were no differences in preoperative meniscus injuries or concomitant meniscus repair or meniscectomy procedures between the 2 groups. There were no differences in preoperative IKDC scores; however, the Medicaid group demonstrated a significantly lower postoperative IKDC score (74.7 vs 90.5; P = .005). Patients insured through Medicaid also demonstrated a significantly lower rate of return to sport and attended significantly fewer PT visits following surgery. There were no significant differences in reinjury or reoperation to the index knee between the 2 groups. The threshold number of PT visits for return to sport was determined to be 31.5 visits. Within the private insurance cohort, 17 of 23 patients (73.9%) exceeded this threshold. However, in the Medicaid cohort, 5 of 18 patients (27.8%) exceeded this threshold. Conclusions: Patients with Medicaid insurance undergoing ACL reconstruction had lower postoperative IKDC scores and were less likely overall to return to sport than their private insurance counterparts at final follow-up in this study. Preoperative IKDC scores, incidence of preoperative meniscus injury, number of concomitant meniscus procedures, average distance from home to PT facility, return to same level of sport, and reinjury and reoperation rate were similar between groups. However, the number of postoperative PT sessions attended by patients insured through Medicaid was significantly lower than private insurance patients. Level of Evidence: III, retrospective comparative study.

Arthroscopic all - Inside repair of meniscal ramp lesions.

Meniscal ramp lesions are disruptions of the posterior meniscotibial attachment of the medial meniscus and are commonly associated with anterior cruciate ligament injuries. However, they can be frequently missed when reviewing standard magnetic resonance imaging and difficult to treat. In this presentation, we describe our approach to repair a meniscal ramp lesion using a minimally invasive all-inside technique. We use this technique for the following surgical indications: meniscal tears involving the peripheral and meniscocapsular attachment of the posterior horn resulting in increased meniscal translation. The procedure is performed using standard arthroscopic portals along with a posteromedial portal placed using spinal needle localisation to ensure access around the lesion. Advantages of this technique include a minimally invasive repair that avoids the typical medial knee incision and dissection needed for traditional inside-out repairs, as well as direct visualisation of the repair site to ensure an appropriately tensioned anatomic repair. Technical pearls including adequate arthroscopic visualisation of the posteromedial compartment allowing the creation of a posteromedial working portal, direct passage of sutures through the edges of the ramp lesion facilitating an anatomic repair, and tensioning of the repair with arthroscopic knots to ensure restoration of the posterior horn stability are all critical to a good outcome. Furthermore, the use of two different curve directions for more displaced tears may be necessary to achieve an anatomic repair. In this case and in our experience, we use a Corkscrew SutureLasso 45° curve left for the meniscus bite and right for the capsular bite, as well as a long 8.25 mm by 70 mm twist-in cannula to accommodate the passing of insertion instrumentation in larger patients.

Placement technique impacts gastrostomy tube-related complications amongst head and neck cancer patients.

OBJECTIVES: Percutaneous endoscopic gastrostomy (PEG) placement is essential for the provision of enteral nutrition in select head and neck cancer (HNC) patients. Minimally invasive tube placement is facilitated through one of two techniques, push or pull, but there have been conflicting results regarding safety profiles of these procedures. The objectives of this study were to determine the association of PEG insertion technique with gastrostomy tube complications, including stomal metastases. METHODS: A multi-institutional retrospective cohort study of patients with HNC undergoing PEG insertion by either the pull (gastroscope assisted) or push (fluoroscopy assisted) technique was performed. Tube-related complications included infection, dislodgement, deterioration, leak, and other. Adjusted analysis was performed via a multivariable logistic regression model. RESULTS: 1,575 patients were included across three institutions. Tube-related complications occurred in 36% of patients, the most common being peristomal leak (13%) and infection (16%). The push technique (OR 2.66, 95% CI: 1.42-4.97), and the presence of T4 disease (OR 4.62, 95% CI: 1.58-13.51), were associated with a greater risk of developing any tube-related complication. Infection rates were similar between pull and push cohorts. All detected stoma metastases occurred with the pull technique, with an overall prevalence of 0.32% amongst the cohort. CONCLUSIONS: The push technique is associated with a greater risk of developing any tube-related complication, but the rate of stomal metastases may be higher with the pull technique. There is potential for quality improvement measures to improve tube-related complications associated with either technique.

Rehabilitation and Return to Play of the Athlete after an Upper Extremity Injury.

Shoulder and elbow injuries during athletic participation are very common and may require operative intervention if refractory to conservative care. In recovering from these upper extremity injuries, proper postoperative rehabilitation and setting reasonable expectations regarding return to play are very important. This review article focuses on the most common surgically treated shoulder and elbow injuries, including rotator cuff tears, SLAP tears, anterior and posterior shoulder instability, and elbow ulnar collateral ligament tears. Rates of return to play after surgical intervention are encouraging in most professional and recreational athletes but are highly dependent on the severity of injury, as well as the demands and position in sport. Real-world strategies for staged successful rehabilitation are presented and discussed.

Optimization of Preoperative Anemia in Lower Limb Joint Replacement Surgery: Assessing the Rates of Allogenic Blood Transfusion and Duration of Hospital Stay.

BACKGROUND: Orthopaedic procedures such as total hip and total knee replacements carry a significant risk of postoperative anemia, necessitating allogenic blood transfusions (ABTs), and an increased hospital length of stay. AIM: Our aim was to investigate whether the implementation of a local protocol designed to detect and treat preoperative anemia resulted in reduced ABT rates and a shorter duration of length of hospital stay (LOS). METHODS: We retrospectively audited 683 patients undergoing primary hip and knee replacements. We collated data for all patients about hospital length of stay and blood transfusions received. Both descriptive statistics and univariate analysis were performed. RESULTS: Approximately 21.6% of the cohort within the study who were anemic at preoperative clinic had a significantly increased median LOS of 2 days (p < .001) and an increased packed red cell transfusion rate compared with non-anemic patients (26.1% vs. 2.21%, p < 001). However, treatment of preoperative anemia did not show any significant difference in transfusion rates compared with patients who did not receive corrective treatment. The median LOS was higher by 1 day in the treated group compared with the nontreated cohort (p = .005). CONCLUSION: There is significant evidence to suggest that preoperative anemia can increase LOS and increase the risk of requiring postoperative blood transfusions. However, anemia should be regarded as a characteristic that can add to the outcome in a cumulative manner, as opposed to an isolated factor. Further research is needed on how to better manage preoperative anemia in order to improve patients' outcomes.

Evolution of gender representation among Canadian OTL-HNS residents: a 27-year analysis.

BACKGROUND: The proportion of females enrolling into medical schools has been growing steadily. However, the representation of female residents among individual specialties has shown considerable variation. The purpose of this study was to compare the trends of gender representation in Otolaryngology - Head and Neck Surgery (OTL-HNS) residency programs with other specialty training programs in Canada. In order to contextualize these findings, a second phase of analysis examined the success rate of applicants of different genders to OTL-HNS residency programs. METHOD: Anonymized data were obtained from the Canadian Residency Matching Service (CaRMS) and from the Canadian Post-M.D. Education Registry (CAPER) from 1988 to 2014. The differences in gender growth rates were compared to other subspecialty programs of varying size. Descriptive analysis was used to examine gender representation among OTL-HNS residents across years, and to compare these trends with other specialties. Bayesian hierarchical models were fit to analyze the growth in program rates in OTL-HNS based on gender. RESULTS: CaRMS and CAPER data over a 27 year period demonstrated that OTL-HNS has doubled its female representation from 20% to 40% between 1990 and 1994 and 2010-2014. The difference in annual growth rate of female representation versus male representation in OTL-HNS over this time period was 2.7%, which was similar to other large specialty programs and surgical subspecialties. There was parity in success rates of female and male candidates ranking OTL-HNS as their first choice specialty for most years. CONCLUSIONS: Female representation in Canadian OTL-HNS residency programs is steadily increasing over the last 27 years. Large variation in female applicant acceptance rates was observed across Canadian universities, possibly attributable to differences in student body or applicant demographics. Factors influencing female medical student career selection to OTL-HNS require further study to mitigate disparities in gender representation and identify barriers to prospective female OTL-HNS applicants.

Canadian Consensus for the Prevention of Blood Loss in Spine Surgery.

STUDY DESIGN: Cross-sectional, modified Delphi approach. OBJECTIVE: The primary objective of this study was to identify patients at risk of increased perioperative blood loss according to the opinion of expert spine surgeons across Canada. The secondary objective was to obtain information about the experts' approach on how to minimize significant blood loss perioperatively. SUMMARY OF BACKGROUND DATA: Significant blood loss in major spinal surgeries has been associated with increased intra- and perioperative complications and costs. The current available evidence regarding risk factors and preventive measures for increased blood loss remains incomplete. METHODS: A modified Delphi approach was employed to generate consensus opinion on the risk factors and preventive measures for significant blood loss in major spinal surgeries. Twenty-five spine surgeons in Canada participated in this study. RESULTS: Among various factors, surgery for the treatment of spine tumors and prolonged operative time of greater than 5 hours were found to be the most important predictive factors for blood loss in spine surgery. On the other hand, appropriate surgical hemostasis was considered the most effective measure for the prevention of blood loss in these surgeries. CONCLUSION: We recommend the reduction of blood loss by means of meticulous hemostasis and shorter operative time when it is safe and possible. This might result in better treatment outcomes. It would also lead to a reduction in costs associated with major spine surgeries and would ultimately lead to greater value-based spine care. LEVEL OF EVIDENCE: 4.

Accuracy of Mobile-Based Audiometry in the Evaluation of Hearing Loss in Quiet and Noisy Environments.

Objectives (1) To compare the accuracy of 2 previously validated mobile-based hearing tests in determining pure tone thresholds and screening for hearing loss. (2) To determine the accuracy of mobile audiometry in noisy environments through noise reduction strategies. Study Design Prospective clinical study. Setting Tertiary hospital. Subjects and Methods Thirty-three adults with or without hearing loss were tested (mean age, 49.7 years; women, 42.4%). Air conduction thresholds measured as pure tone average and at individual frequencies were assessed by conventional audiogram and by 2 audiometric applications (consumer and professional) on a tablet device. Mobile audiometry was performed in a quiet sound booth and in a noisy sound booth (50 dB of background noise) through active and passive noise reduction strategies. Results On average, 91.1% (95% confidence interval [95% CI], 89.1%-93.2%) and 95.8% (95% CI, 93.5%-97.1%) of the threshold values obtained in a quiet sound booth with the consumer and professional applications, respectively, were within 10 dB of the corresponding audiogram thresholds, as compared with 86.5% (95% CI, 82.6%-88.5%) and 91.3% (95% CI, 88.5%-92.8%) in a noisy sound booth through noise cancellation. When screening for at least moderate hearing loss (pure tone average >40 dB HL), the consumer application showed a sensitivity and specificity of 87.5% and 95.9%, respectively, and the professional application, 100% and 95.9%. Overall, patients preferred mobile audiometry over conventional audiograms. Conclusion Mobile audiometry can correctly estimate pure tone thresholds and screen for moderate hearing loss. Noise reduction strategies in mobile audiometry provide a portable effective solution for hearing assessments outside clinical settings.