Personal protection equipment: Preliminary evidence of effectiveness from a three-phase simulation program.

Background: Healthcare providers carry the occupational risk of being exposed to pathogens. Personal Protection Equipment (PPE) requires proficiency whenever used. Yet, evidence shows significant errors and variation in competency when applying PPE. Objective: In this study, we developed a three-phase intervention to promote PPE proficiency. Methods: Education and assessment of participants' PPE knowledge and skills occurred at a large academic university in Western Canada. Participants first completed an online module; second, they experienced one-on-one coaching and deliberate practice with infection control professionals; and third, participants managed a COVID-19 clinical simulation scenario. The measured outcomes include a 15-item pre- and post-knowledge test and a pre- and post-skills assessment of donning and doffing behaviors. These behaviors were observed from video recordings and were assessed using two standardized checklists. Results: Knowledge and donning/doffing post-test scores (11.73, 0.95, and 0.96, respectively) were significantly higher after completing all three phases of the educational intervention, p < .001. Conclusions: An online module alone is insufficient for PPE knowledge and skill development. Rather, a module followed by practice and simulation allows learners to gain proficiency.

Implementing paediatric patient-reported outcome measures in outpatient asthma clinics: a feasibility assessment study.

OBJECTIVE: Implementation of patient-reported outcome measures (PROMs) is limited in paediatric routine clinical care. The KidsPRO programme has been codesigned to facilitate the implementation of PROMs in paediatric healthcare settings. Therefore, this study (1) describes the development of innovative KidsPRO programme and (2) reports on the feasibility of implementing PedsQL (Pediatric Quality of Life Inventory) PROM in asthma clinics using the KidsPRO programme. DESIGN: Feasibility assessment study. SETTING: Outpatient paediatric asthma clinics in the city of Calgary, Canada. PARTICIPANTS: Five paediatric patients, four family caregivers and three healthcare providers were recruited to pilot the implementation of PedsQL PROM using KidsPRO. Then, a survey was used to assess its feasibility among these study participants. MAIN OUTCOME MEASURES: Participants' understanding of using PROMs, the adequacy of support provided to them, the utility of using PROMs as part of their appointment, and their satisfaction with using PROMs. ANALYSES: The quantitative data generated through closed-ended questions was analysed and represented in the form of bar charts for each category of study participants (ie, patients, their family caregivers and healthcare providers). The qualitative data generated through the open-ended questions were content analysed and categorised into themes. RESULTS: The experience of using PROMs was overwhelmingly positive among patients and their family caregivers, results were mixed among healthcare providers. Qualitative data collected through open-ended questions also complemented the quantitative findings. CONCLUSION: The evidence from this study reveals that the implementation of PROMs in routine paediatric clinical care asthma clinics in Alberta is seems to be feasible.

Uptake of pediatric patient-reported outcome and experience measures and challenges associated with their implementation in Alberta: a mixed-methods study.

BACKGROUND: Implementing Patient-reported Outcome Measures (PROMs) and Patient-reported Experience Measures (PREMs) is an effective way to deliver patient- and family-centered care (PFCC). Although Alberta Health Services (AHS) is Canada's largest and fully integrated health system, PROMs and PREMs are yet to be routinely integrated into the pediatric healthcare system. This study addresses this gap by investigating the current uptake, barriers, and enablers for integrating PROMs and PREMs in Alberta's pediatric healthcare system. METHODS: Pediatric clinicians and academic researchers with experience using PROMs and PREMs were invited to complete a quantitative survey. Additionally, key stakeholders were qualitatively interviewed to understand current challenges in implementing pediatric PROMs and PREMs within AHS. Quantitative data gathered from 22 participants were descriptively analyzed, and qualitative data from 14 participants were thematically analyzed. RESULTS: Participants identified 33 PROMs and 6 PREMs showing diversity in the types of pediatric PROMs and PREMs currently being used in Alberta and their mode of administration. The qualitatively identified challenges were associated with patients, family caregivers, and clinicians. The absence of system-level support, such as integration within electronic medical records, is considered a significant system-level challenge. CONCLUSIONS: The significant variation in the types of PROMs and PREMs used, the rationale for their use, and their mode of administration demonstrate the diverse and sporadic use of these measures in Alberta. These findings highlight the need for province-wide uniform implementation of pediatric PROMs and PREMs in Alberta. Our results could benefit healthcare organizations in developing evidence-based PROM and PREM implementation strategies in pediatrics.

Communication in the conversation between preceptors and physicians-in-training during simulation: what is not said.

BACKGROUND: There is an abundance of published communication models, but few explicate how professional conversation may include the communication of some information but exclude the sharing of one's inner thoughts and feelings. This conceptualization of communication was applied to guide our understanding of how medical learners interact with preceptors at the bedside in a high-fidelity simulation when managing a patient case. METHODS: A total of 84 medical learners (42 residents and 42 medical students) participated in a high-fidelity simulation. After they interacted with the patient for about 10 min, a preceptor entered and offered an equivocal or questionable recommendation about diagnosis or treatment. This type of recommendation was designed to trigger a difficult conversation that would create an opportunity for the learners to share facts, thoughts, points of view, and feelings about the patient with the preceptor. The preceptor left the room, and the learners completed their assessment once they made a diagnosis and treatment recommendations. Two raters independently coded the communication between the preceptor and learners by independently watching video recordings. RESULTS: Of the three types of communication styles identified in the model, the majority of learners (n = 56, 66.70%) engaged in a muted conversation where they shared little or no clarification of facts about the patient's case, their feelings or thoughts, nor did they explore their preceptor's point of view. CONCLUSIONS: Learners may not feel comfortable exploring or expressing thoughts and feelings in front of their preceptors. We recommend that preceptors directly engage learners in conversation.

Eliciting Patient Experiences About Their Care After Cardiac Surgery.

BACKGROUND: Experience surveys provide an opportunity for patients to give their feedback about health care processes and services. Unfortunately, the most current surveys have been designed as "one-size fits-all" tools, and thus, do not take into account items pertaining to specific clinical groups. The objective of this study was to gain a deeper understanding of the specific aspects of care deemed important to cardiac surgery patients. METHODS: Individual semistructured telephone interviews were conducted with a cohort of patients who had previously underwent cardiac surgery. Interviews were recorded and transcribed. Using a phenomenological approach, a thematic analysis was used to generate a list of themes and subthemes deemed important by participants. RESULTS: Eight interviews were conducted in July and August 2019. Participants included 7 men and 1 woman, ranging from 55 to 84 years of age. Five key themes emerged from the data: (1) overall experience; (2) communication; (3) the physical hospital environment; (4) care needs and ongoing management; and (5) person-centred care. Our interviews revealed that participants had many overwhelmingly positive experiences with care. Through reports of their own experiences, participants highlighted important areas that might be improved. CONCLUSIONS: Our results confirm and expand upon those highlighted in quantitative research by our group. Findings and knowledge derived from this study might be used to inform quality improvement activities. These might also play a key role in the development of a patient experience survey, specifically for those who undergo cardiac surgery; thus addressing a potential limitation of surveys currently in use.

CONTEXTE: Les sondages sur l'expérience offrent l'occasion aux patients de transmettre leur point de vue au sujet des services et des processus de soins de santé. Malheureusement, la plupart des sondages actuels sont conçus comme des outils universels, et ne prenent donc pas en considération certains aspects propres à des groupes cliniques précis. L'objectif de cette étude est de mieux cerner les aspects précis des soins qui sont jugés importants par les patients qui ont subi une intervention chirurgicale cardiaque. MÉTHODOLOGIE: Des entretiens téléphoniques individuels semi-structurés ont été menés avec une cohorte de patients ayant subi une intervention chirurgicale cardiaque. Les entretiens ont été enregistrés et retranscrits. Une analyse thématique utilisant une approche phénoménologique a été effectuée pour générer une liste de thèmes et de sous-thèmes jugés importants par les participants. RÉSULTATS: Huit entretiens ont été réalisés en juillet et en août 2019. Les participants regroupaient sept hommes et une femme, âgés de 55 à 84 ans. Les données recueillies ont permis de cerner cinq thèmes clés : 1) expérience globale; 2) communication; 3) environnement physique à l'hôpital; 4) besoins en matière de soins et prise en charge continue; et 5) soins axés sur le patient. Nos entretiens ont révélé que les participants avaient eu plusieurs expériences de soins extrêmement positives. En relatant leurs propres expériences, les participants ont souligné d'importants aspects qui pourraient être améliorés. CONCLUSIONS: Nos résultats confirment ceux des recherches quantitatives effectuées par notre groupe, et viennent les étayer. Les données et les résultats générés par cette étude pourraient être utilisés pour mettre au point des mesures visant l'amélioration de la qualité. Ils pourraient également jouer un rôle important dans la création d'un sondage sur l'expérience des patients, et plus précisément l'expérience des patients ayant subi une intervention chirurgicale cardiaque, et ainsi remédier aux limites possibles des sondages utilisés à l'heure actuelle.

Translating caring competencies to remote working environments: a systematic review protocol.

INTRODUCTION: Caring professions attend to the health, educational and social needs of society rather than its material needs. Caring professionals are a vital part of the world's response to COVID-19, yet the global pandemic and its aftermath have significantly changed the ways in which care is provided. The rapid pivot to remote care, where the essential caring cues and opportunities are not as readily available, has put unprecedented pressure on caring professions. There is currently a lack of clear understanding and accepted standards for teaching caring profession students how to provide care remotely. The objective of this systematic review is to identify and assess the ways in which educators can integrate online learning opportunities to help students develop effective caring practices and translate these into today's remote and virtual care environments. METHODS AND ANALYSIS: This systematic review will consider diverse quantitative, qualitative and mixed-methods studies of innovative online education initiatives and required technology for caring profession education. Articles will be retrieved from academic databases and limited to articles reporting primary data and published in English within the last 10 years. Data extraction procedures will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guideline. The methodological quality of all studies will be assessed using the Effective Public Health Practice Project Quality Assessment Tool and/or the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research. Study characteristics will be tabulated and narratively synthesised to integrate and explore relationships within the data. ETHICS AND DISSEMINATION: No ethics approval is required to conduct this review. Review findings will be disseminated through peer-reviewed publications, conference presentations and be used to inform and guide caring profession education policy, practice and research agendas with the goal of improving education for caring profession students, and care for the patients, clients and learners they serve.

Factors Influencing Inpatient Insulin Management of Adults With Type 1 and Type 2 Diabetes by Residents and Medical Students.

OBJECTIVES: The day-to-day management of diabetes is often the responsibility of resident physicians in teaching hospitals, yet studies have consistently shown that learners lack confidence and knowledge of inpatient insulin titration. We sought to elucidate factors that influence inpatient management of diabetes by medical learners. We predicted that there would be conscious and unconscious variables at play, and we sought to determine the process by which learners arrived at insulin titration decisions. METHODS: We administered a survey using a hypothetical case based on script concordance testing in 88 medical students and residents at the University of Calgary. We used multilevel, mixed-effects linear regression and random-effects meta-analysis to compare clerks' and residents' insulin prescribing, confidence in prescribing decisions and concordance with endocrinologists. RESULTS: Residents had higher confidence than clerks, yet were less concordant with the insulin decisions of staff endocrinologists. Both residents and clerks prescribed more insulin when the reported blood glucose was higher, or the patient had positive ketones and prescribed less insulin when the patient had hypoglycemic unawareness. Residents prescribed a higher dose of insulin when the charge nurse reported the result compared with a student nurse, but this variable did not significantly impact prescribing by clerks. CONCLUSIONS: We propose a model in which learner factors (knowledge, confidence, experience), patient variables and perceived expectations influence insulin titration decisions via analytical and heuristic processes. We propose that educational interventions designed to improve inpatient glycemic control must, therefore, address both knowledge and systems factors.

Peer mentoring in medical residency education: A systematic review.

BACKGROUND: Medical residents may experience burnout during their training, and a lack of social support. This can impact their overall wellbeing and ability to master key professional competencies. We explored, in this study, the extent to which peer mentorship promotes psychosocial wellbeing and the development of professional competencies in medical residency education. METHODS: We searched six databases (MEDLINE, EMBASE, PsycINFO, Academic Research Complete, ERIC, Education Research Complete) for studies on peer mentoring relationships in medical residency. We selected any study where authors reported on outcomes associated with peer mentoring relationships among medical residents. We applied no date, language, or study design limits to this review. RESULTS: We included nine studies in this systematic review. We found that medical residents received essential psychosocial supports from peers, and motivation to develop academic and career competencies. Medical residents in peer-mentoring relationships also reported increased overall satisfaction with their residency training programs. CONCLUSIONS: Peer-mentoring relationships can enhance the development of key professional competencies and coping mechanisms in medical residency education. Further rigorous research is needed to examine the comparative benefits of informal and formal peer mentoring, and identify best practices with respect to effective design of peer-mentorship programs.

CONTEXTE: Les résidents en médecine peuvent ressentir un épuisement professionnel durant leur formation, et un manque de soutien social. Ceci peut affecter bien-être global et leur capacité à maîtriser des compétences professionnelles essentielles. Au cours de cette étude, nous avons examiné dans quelle mesure le mentorat par des pairs favorisait le bien-être psychosocial et l'acquisition de compétences professionnelles chez les médecins résidents. MÉTHODOLOGIE: Nous avons cherché dans six bases de données (MEDLINE, EMBASE, PsycINFO, Academic Research Complete, ERIC, Education Research Complete) des études sur le mentorat par des pairs pendant la résidence en médecine. Nous avons retenu toutes les études dont les auteurs avaient présenté des résultats associés aux relations de mentorat par des pairs chez les résidents en médecine, sans limite de date, la langue ou le devis. RÉSULTATS: Nous avons inclus 9 études dans cette revue systématique. Nous avons découvert que les médecins résidents recevaient un soutien psychosocial essentiel de la part des pairs et que ceux-ci les motivaient à acquérir des compétences universitaires et professionnelles. On a aussi constaté que les médecins résidents qui bénéficiaient d'un mentorat par des pairs étaient, de façon globale, plus satisfaits de leur programme de résidence. CONCLUSIONS: Le mentorat par des pairs peut favoriser l'acquisition de compétences professionnelles clés et de mécanismes d'adaptation au cours de la résidence en médecine. Il faudrait mener d'autres recherches rigoureuses pour comparer les avantages du mentorat informel à ceux du mentorat structuré et cerner les pratiques exemplaires de conception de programmes efficaces de mentorat par des pairs.

Hydroxyurea for nontransfusion-dependent ß-thalassemia: A systematic review and meta-analysis.

OBJECTIVE/BACKGROUND: Nontransfusion-dependent ß-thalassemia (NTDßT) syndromes consist of ß-thalassemia intermedia and moderate hemoglobin E/ß thalassemias. They are characterized by varying degrees of chronic anemia and a wide spectrum of complications due to ineffective erythropoiesis and iron overload from chronic transfusions. Hydroxyurea (HU), an oral chemotherapeutic drug, is anticipated to decrease disease severity. METHODS: We performed a meta-analysis to evaluate the clinical efficacy and safety of HU in NTDßT patients of any age. MEDLINE, EMBASE, Cochrane databases, and major conference proceedings for studies that assessed HU in NTDßT patients were searched. Qualities of eligible studies were assessed by National Institutes of Health tools. RESULTS: Seventeen studies, collectively involving 709 patients, fulfilled the eligibility criteria. HU was associated with a significant decrease in transfusion need in severe NTDßT with complete and overall (≥50%) response rates of 42% and 79%, respectively. For mild NTDßT, HU was effective in raising hemoglobin by 1g/L in 64% of patients. CONCLUSION: HU appears to be effective, well tolerated, and associated with mild and transient adverse events. NTDßT patients may benefit from a trial of HU, although large randomized clinical trials assessing its efficacy should be conducted to confirm the findings of this meta-analysis and to assess its long-term toxicity and response sustainability.

Hydroxyurea for lifelong transfusion-dependent ß-thalassemia: A meta-analysis.

OBJECTIVE: Chronic blood transfusion remains the most feasible therapeutic option for lifelong transfusion-dependent ß-thalassemia (lifelong TDßT). However, it is associated with serious risks and complications. Hydroxyurea (HU), an oral chemotherapeutic drug, is expected to increase hemoglobin levels, thereby minimizing the burden of blood transfusion and its complications. Growing literature over the last twenty years suggests promising results of the use HU in lifelong TDßT; however, its role and safety remain unanswered questions. The objective of this study was to evaluate the clinical efficacy and safety of HU in patients with lifelong TDßT. METHODS: MEDLINE, EMBASE, Cochrane databases, and major preceding conferences for studies that assessed HU in lifelong TDßT patients were searched. The effect size was estimated as a proportion (responder/sample size). RESULTS: Eleven observational studies, collectively involving 859 patients, fulfilled eligibility criteria. HU was associated with a significant decrease in transfusion need with complete and overall (≥50%) response rates of 26% [95% confidence interval (CI), 13-41%] and 60% (95% CI, 41-78%), respectively. No serious adverse effects were reported. All of the studies had several limitations, such as lack of a comparison group. CONCLUSION: HU appears to be effective, well tolerated; however, large randomized clinical trials should be done to confirm such findings.

Complications and Adverse Events of a Randomized Clinical Trial Comparing 3 Graft Types for ACL Reconstruction.

OBJECTIVE: Complications/adverse events of anterior cruciate ligament (ACL) surgery are underreported, despite pooled level 1 data in systematic reviews. All adverse events/complications occurring within a 2-year postoperative period after primary ACL reconstruction, as part of a large randomized clinical trial (RCT), were identified and described. DESIGN: Prospective, double-blind randomized clinical trial. Patients and the independent trained examiner were blinded to treatment allocation. SETTING: University-based orthopedic referral practice. PATIENTS: Three hundred thirty patients (14-50 years; 183 males) with isolated ACL deficiency were intraoperatively randomized to ACL reconstruction with 1 autograft type. Graft harvest and arthroscopic portal incisions were identical. INTERVENTION: Patients were equally distributed to patellar tendon (PT), quadruple-stranded hamstring tendon (HT), and double-bundle (DB) hamstring autograft ACL reconstruction. MAIN OUTCOME MEASURES: Adverse events/complications were patient reported, documented, and diagnoses confirmed. RESULTS: Two major complications occurred: pulmonary embolism and septic arthritis. Twenty-four patients (7.3%) required repeat surgery, including 25 separate operations: PT = 7 (6.4%), HT = 9 (8.2%), and DB = 8 (7.3%). Repeat surgery was performed for meniscal tears (3.6%; n = 12), intra-articular scarring (2.7%; n = 9), chondral pathology (0.6%; n = 2), and wound dehiscence (0.3%; n = 1). Other complications included wound problems, sensory nerve damage, muscle tendon injury, tibial periostitis, and suspected meniscal tears and chondral lesions. Overall, more complications occurred in the HT/DB groups (PT = 24; HT = 31; DB = 45), but more PT patients complained of moderate or severe kneeling pain (PT = 17; HT = 9; DB = 4) at 2 years. CONCLUSIONS: Overall, ACL reconstructive surgery is safe. Major complications were uncommon. Secondary surgery was necessary 7.3% of the time for complications/adverse events (excluding graft reinjury or revisions) within the first 2 years. LEVEL OF EVIDENCE: Level 1 (therapeutic studies). CLINICAL RELEVANCE: This article reports on the complications/adverse events that were prospectively identified up to 2 years postoperatively, in a defined patient population participating in a large double-blind randomized clinical trial comparing PT, single-bundle hamstring, and DB hamstring reconstructions for ACL rupture.

Targeted needs assessment for a transitional "boot camp" curriculum for pediatric surgery residents.

INTRODUCTION: Transition periods in medical education are associated with increased risk for learners and patients. For pediatric surgery residents, the transition to training is especially difficult as learners must adjust to new patient populations. In this study we perform a targeted needs assessment to determine the ideal content and format of a pediatric surgery boot camp to facilitate the transition to residency. METHODS: A needs assessment survey was developed and distributed to pediatric surgery residents and staff across North America. The survey asked participants to rank 30 pediatric surgical diagnoses, 20 skills, and 11 physiological topics on "frequency" and "importance". Items were then ranked using empirical methods. The survey also evaluated the preferred boot camp format. RESULTS: In total, 12 residents and 23 staff completed the survey. No significant differences were identified between staff and residents in survey responses. The top 5 topics identified for inclusion in a boot camp were: (1) fluid and electrolyte management, (2) appendicitis, (3) pediatric hernias, (4) nutrition and (5) pain management. The preferred format for a boot camp was 3-4days in duration applying a blend of educational methods. CONCLUSIONS: Based on the results of the needs assessment survey, a novel pediatric surgery boot camp curriculum can be developed.

Does it really spin? Intra-medullary nailing of segmental tibial fractures--a cadaveric study.

This study aims to quantify the effect of intra-medullary reaming on rotational displacement of both long diaphyseal segmental tibial fractures (Melis Type III) and short (Melis Type IV) in a cadaveric model with differing degrees of soft tissue stripping. Eighteen fresh-frozen cadaveric specimens (9 matched pairs), median age at death was 85 years (68-92) were used to perform a standardized reaming procedure for an intra-medullary tibial nail and the rotational displacement of the segmental fracture fragment (long and short diaphyseal fractures) was recorded. Rotational displacement was recorded using a goniometer and K-wires positioned in the proximal, segmental and distal fracture fragments. Type III fractures rotate more than Type IV fractures (p<0.0001). In Type III fractures reaming to fit with 0%, 50% and 100% soft tissue stripping resulted in rotational displacement of 11.7 SD 12), 13 (SD 16.5) and 307.3 (SD 118.1) degrees respectively. In Type IV fractures reaming to fit with 0%, 50% and 100% soft tissue stripping resulted in rotational displacement of 8.5 (SD 5.5), 12.7 (SD 9.9) and 135.3 (SD 147.1) degrees respectively. The use of a pointed reduction clamp or unicortical plate eliminated rotational displacement. Reaming is a major risk factor for rotational displacement of segmental tibial fractures irrespective of the degree of soft tissue stripping. Long diaphyseal segmental fractures rotate more than shorter segmental fractures. We recommend always clamping the fracture during reaming to avoid rotational displacement.

Electrothermal arthroscopic capsulorrhaphy: old technology, new evidence. A multicenter randomized clinical trial.

BACKGROUND: Radiofrequency technology for shoulder instability was rapidly adopted despite limited clinical evidence and a poor understanding of its indications. Reports of serious adverse events followed, leading to its abandonment. This paper presents findings from a multicenter randomized clinical trial evaluating the safety and efficacy of electrothermal arthroscopic capsulorrhaphy (ETAC) compared with open inferior capsular shift (ICS) and reviews the role of randomized trials in adopting new technology. METHODS: Patients (>14 years) diagnosed with multidirectional instability or multidirectional laxity with anteroinferior instability and failed nonoperative treatment were enrolled. Patients with bone lesions or labral, biceps anchor, or full-thickness rotator cuff tears were excluded intraoperatively. Outcomes included Western Ontario Shoulder Instability Index, function and recurrent instability at 2 years postoperatively, and surgical times. RESULTS: Fifty-four subjects (mean age, 23 years; 37 women) were randomized to ETAC (n = 28) or open ICS (n = 26). The groups were comparable at baseline, except for external rotation at the side. At 2 years postoperatively, there were no statistically or clinically significant differences between groups for the Western Ontario Shoulder Instability Index (P = .71), American Shoulder and Elbow Surgeons score (P = .43), Constant score (P = .43), and active range of motion. Recurrent instability was not statistically different (ETAC, 2; open, 4; P = .41). ETAC (23 minutes) was significantly shorter than open ICS (59 minutes) (P < .01) surgery. Three subjects (1 ETAC, 2 open) had stiff shoulders. CONCLUSIONS: At 2 years postoperatively, quality of life and functional outcomes between groups were not clinically different. ETAC had fewer complications and episodes of recurrence compared with open surgery. This evidence reinforces the need to critically evaluate new technology before widespread clinical use.

Identifying areas of weakness in thoracic surgery residency training: a comparison of the perceptions of residents and program directors.

OBJECTIVE: To identify core thoracic surgery procedures that require increased emphasis during thoracic surgery residency for residents to achieve operative independence and to compare the perspectives of residents and program directors in this regard. METHODS: A modified Delphi process was used to create a survey that was distributed electronically to all Canadian thoracic surgery residents (12) and program directors (8) addressing the residents' ability to perform 19 core thoracic surgery procedures independently after the completion of residency. Residents were also questioned about the adequacy of their operative exposure to these 19 procedures during their residency training. A descriptive summary including calculations of frequencies and proportions was conducted. The perceptions of the 2 groups were then compared using the Fisher exact test employing a Bonferroni correction. The relationship between residents' operative exposure and their perceived operative ability was explored in the same fashion. RESULTS: The response rate was 100% for residents and program directors. No statistical differences were found between residents' and program directors' perceptions of residents' ability to perform the 19 core procedures independently. Both groups identified lung transplantation, first rib resection, and extrapleural pneumonectomy as procedures for which residents were not adequately prepared to perform independently. Residents' subjective ratings of operative exposure were in good agreement with their reported operative ability for 13 of 19 procedures. CONCLUSION: This study provides new insight into the perceptions of thoracic surgery residents and their program directors regarding operative ability. This study points to good agreement between residents and program directors regarding residents' surgical capabilities. This study provides information regarding potential weaknesses in thoracic surgery training, which may warrant an examination of the curricula of existing programs as well as a reconsideration of what the scope of practice of a general thoracic surgeon should entail.

A randomized clinical trial comparing open and arthroscopic stabilization for recurrent traumatic anterior shoulder instability: two-year follow-up with disease-specific quality-of-life outcomes.

BACKGROUND: The literature comparing open and arthroscopic repair for glenohumeral instability is conflicting. We performed a prospective, expertise-based, randomized clinical trial to compare open shoulder stabilization with arthroscopic shoulder stabilization by measuring quality-of-life outcomes and recurrence rates at two years among patients treated for traumatic anterior shoulder instability. METHODS: Computer-generated, variable-block-size, concealed randomization allocated 196 patients to either the open-repair group (n = 98) or the arthroscopic-repair group (n = 98). An expertise-based randomization design was employed to avoid a differential bias in terms of physician experience. Outcomes were measured at baseline, at three and six months postoperatively, and at one and two years postoperatively with use of the Western Ontario Shoulder Instability Index (WOSI) and the American Shoulder and Elbow Surgeons (ASES) functional outcome scale. Recurrent instability was also analyzed. RESULTS: There were no significant differences in outcome scores at baseline. At two years, seventy-nine patients in the open group and eighty-three patients in the arthroscopic group were available for follow-up. There was no significant difference in mean WOSI scores between the groups; the mean WOSI score (and standard deviation) for the open group was 85.2 ± 20.4 (95% confidence interval [CI] = 80.5 to 89.8), and for the arthroscopic group, 81.9 ± 19.8 (95% CI = 77.4 to 86.4); p = 0.31. There was also no significant difference in mean ASES scores: 91.4 ± 12.7 (95% CI = 88.5 to 94.4) for the open group and 88.2 ± 15.9 (95% CI = 84.6 to 91.8) for the arthroscopic group; p = 0.17. Recurrence rates at two years were significantly different: 11% in the open group and 23% in the arthroscopic group (p = 0.05). Recurrent instability was more likely in patients with a preoperative Hill-Sachs lesion and in male patients who were twenty-five years old and younger. There was no significant difference in shoulder motion between the groups at two years. CONCLUSIONS: There was no difference between open and arthroscopic repair in terms of patient quality of life. Open repair resulted in a significantly lower risk of recurrence. Secondary outcome data from this trial suggest that open surgical repair may be recommended to reduce the risk of recurrent instability in younger male patients with a Hill-Sachs lesion.

Paediatric femoral shaft fractures: what are the concomitant injuries?

INTRODUCTION: Trauma remains a substantial cause of paediatric morbidity and mortality. Femur fractures are common in children, and frequently are the result of high-energy mechanisms of injury. A complete description of missed injuries in this population has not previously been described. MATERIALS AND METHODS: A retrospective chart review of patients presenting to the Alberta Children's Hospital with femoral shaft fractures was performed. Associated injuries, and injuries with delayed diagnosis were recorded. RESULTS: Twenty-percent of the patients suffered at least one other injury with their femur fracture. Six-percent of injuries had a delayed diagnosis, corresponding to three-percent of the patients reviewed. CONCLUSION: There is a risk of missed injuries in the paediatric patient presenting with a femoral shaft fracture. Paediatric trauma teams and paediatric orthopaedic teams must be aware of this risk to help reduce the incidence of missed injuries. A tertiary trauma survey on children with paediatric femoral shaft fractures may help diagnose missed injuries.

Reliability of the thoracolumbar injury classification and severity score and comparison with the denis classification for injury to the thoracic and lumbar spine.

STUDY DESIGN: This study is a series of thoracic and lumbar spine fracture cases to assess the reliability of thoracolumbar injury classification and severity score (TLICS) in simulated clinical scenarios. OBJECTIVE: To determine the inter- and intraobserver reliability of TLICS compared with the Denis classification system, and to assess differences based on rater characteristics. SUMMARY OF BACKGROUND DATA: Thoracolumbar injury severity score and TLICS have been subjected to reliability testing using less robust statistical analysis. Both systems have demonstrated poor to good reliability, with particularly weak agreement on the status of the posterior ligamentous complex. METHODS: Fifty-four spine fracture cases were selected from a chart review. These cases were scored on 2 occasions by 11 experts using both TLICS and the Denis classification systems. Reliability was assessed using a generalizability coefficient. The primary outcome was interobserver reliability. Secondary outcomes were intraobserver reliability, difference between orthopedic and neurosurgeons, as well as trainees and consultants, and correlation with treatment recommendations. RESULTS: TLICS demonstrated good interobserver agreement of 0.73 to 0.74. The posterior ligamentous complex component was the least reliable. The Denis classification also demonstrated good reliability between observers, but was least reliable for flexion-distraction injuries. In addition, interobserver reliability between the Denis classification and TLICS morphology subcomponent was strong. TLICS also predicted the need for operative treatment as determined by the experts scoring the injuries. CONCLUSION: TLICS is a reliable system for assessing fractures of the thoracic and lumbar spine when used by experts. Similar to previous studies, the posterior ligamentous complex subcomponent score was the least reliable component. Reliability assessment using a generalizability coefficient is a robust method for validating fracture classifications.

A meta-analysis of common risk factors associated with the diagnosis of developmental dysplasia of the hip in newborns.

BACKGROUND: Although there is no clear consensus about the process of screening for developmental dysplasia of the hip (DDH), there are six common risk factors associated with DDH in patients less than 6 months of age (breech presentation, sex, family history, first-born, side of hip, and mode of delivery). METHODS: A meta-analysis of published studies was conducted to identify the relative risk ratio of the six commonly known risk factors. A total of 31 primary studies consisting of 20,196 DDH patients met the following inclusion criteria: (1) contained empirical data on at least one common risk factor, (2) were peer-reviewed from an English language scientific journal, (3) included patients less or equal to 6 months of age, and (4) identified method of diagnosis (e.g., ultrasound, radiographs or clinical examination). RESULTS: Fixed effect and random effects models with 95% confidence intervals were calculated for each of the six risk factors. Reported relative risk ratio (RR) for each factor in newborns was: breech presentation 3.75 (95% CI: 2.25-6.24), females 2.54 (95% CI: 2.11-3.05), left hip side 1.54 (95% CI: 1.25-1.90), first born 1.44 (95% CI: 1.12-1.86), and family history 1.39 (95% CI: 1.23-1.57). A non-significant RR value of 1.22 (95% CI: 0.46-3.23) was found for mode of delivery. CONCLUSION: Results suggest that ultrasound and radiology screening methods be used to confirm DDH in newborns that present with one or a combination of the following common risk factors: breech presentation, female, left hip affected, first born and family history of DDH.

Primary colorectal lymphoma-clinical outcomes in a population-based series.

PURPOSE: The purpose of this study was to investigate the characteristics and the outcomes of primary colorectal lymphomas using a population-based registry. METHODS: All cases of colorectal lymphoma diagnosed between 1980 and 2007 were identified using a provincial cancer registry. Patients meeting Dawson's criteria and having a negative bone marrow biopsy were included. RESULTS: One hundred ten cases of colorectal lymphoma were identified, 43 met the inclusion criteria. The majority of patients was male (86%), and the median age at diagnosis was 62 (range 26-82) years. Tumors were mostly located in the cecum (51.1%) and rectum (20.9%). The 5-year overall survival rate calculated by the Kaplan-Meier method was 57%. Age under 60 was associated with a better median survival time (265 vs 54 months; p < 0.0001). The surgical treatment was associated with a better overall survival compared to medical treatment alone (110 vs 56 months; p = 0.083). Tumors located in the rectum were associated with a decreased overall survival (41 months vs 110 months; p = 0.065). CONCLUSIONS: Primary colorectal lymphoma is a rare disease. The age at diagnosis is an important predictor of outcome. Surgical resection may be associated with improved survival. Rectal lymphoma appears to be associated with a worse outcome and may warrant more aggressive therapy.