OPerative versus non-opERAtive management of isolated ULNAr diaphyseal fractures (OPERA-Ulna): protocol for a randomized controlled trial.

Aims: Isolated fractures of the ulnar diaphysis are uncommon, occurring at a rate of 0.02 to 0.04 per 1,000 cases. Despite their infrequency, these fractures commonly give rise to complications, such as nonunion, limited forearm pronation and supination, restricted elbow range of motion, radioulnar synostosis, and prolonged pain. Treatment options for this injury remain a topic of debate, with limited research available and no consensus on the optimal approach. Therefore, this trial aims to compare clinical, radiological, and functional outcomes of two treatment methods: open reduction and internal fixation (ORIF) versus nonoperative treatment in patients with isolated ulnar diaphyseal fractures. Methods: This will be a multicentre, open-label, parallel randomized clinical trial (under National Clinical Trial number NCT01123447), accompanied by a parallel prospective cohort group for patients who meet the inclusion criteria, but decline randomization. Eligible patients will be randomized to one of the two treatment groups: 1) nonoperative treatment with closed reduction and below-elbow casting; or 2) surgical treatment with ORIF utilizing a limited contact dynamic compression plate and screw construct. The primary outcome measured will be the Disabilities of the Arm, Shoulder and Hand questionnaire score at 12 months post-injury. Additionally, functional outcomes will be assessed using the 36-Item Short Form Health Survey and pain visual analogue scale, allowing for a comparison of outcomes between groups. Secondary outcome measures will encompass clinical outcomes such as range of motion and grip strength, radiological parameters including time to union, as well as economic outcomes assessed from enrolment to 12 months post-injury. Ethics and dissemination: This trial has been approved by the lead site Conjoint Health Research Ethics Board (CHREB; REB14-2004) and local ethics boards at each participating site. Findings from the trial will be disseminated through presentations at regional, national, and international scientific conferences and public forums. The primary results and secondary findings will be submitted for peer-reviewed publication.

Connect 2 Care, a Novel Community Outreach Program for Vulnerably Housed Patients With High Acute Care Use: A Mixed-Methods Study Protocol.

Introduction: Vulnerably housed individuals, especially those experiencing homelessness, have higher acute care use compared with the general population. Despite available primary care and social services, many face significant challenges accessing needed services. Connect 2 Care (C2C) is a novel transitional case management program that includes registered nurses and health navigators with complementary expertise in chronic disease management, mental health and addictions, social programs, community health, and housing, financial, transportation and legal resources. C2C bridges acute care and community services to improve care coordination. Methods and Analysis: We will perform a mixed-methods evaluation of the C2C program according to the Donabedian framework of structure, process and outcome, to understand how program structure and process, coupled with contextual factors, influence outcomes in a novel intervention. Eligible patients are homeless or unstably housed adults with complex health conditions and high acute care use. Change in emergency department visit rate 12-months after program enrolment is the primary outcome. Secondary outcomes include 12-month post-enrolment hospital admissions, cumulative hospital days, health-related quality of life, housing status, primary care attachment and substance use. Qualitative methods will explore experiences with the C2C program from multiple perspectives and an economic evaluation will assess cost-effectiveness. Discussion: Academic researchers partnered with community service providers to evaluate a novel transitional case management intervention for vulnerably housed patients with high acute-care use. The study uses mixed-methods to evaluate the Connect 2 Care program according to the Donabedian framework of structure, process and outcome, including an assessment of contextual factors that influence program success. Insights gained through this comprehensive evaluation will help refine the C2C program and inform decisions about sustainability and transferability to other settings in Canada.

"Who is the right patient?" Insights into decisions to transfer pediatric trauma patients.

OBJECTIVE: We aim to determine what variables may influence physician decision-making about transfer of pediatric patients from a Level III Trauma Center (L3TC) to a Pediatric Trauma Center (PTC). METHODS: Emergency L3TC physicians and PTC emergency physicians/TTLs were surveyed with clinical scenarios of children presenting to a L3TC with 5 injury parameters: age, hemodynamic status, GCS, intra-abdominal injury, femur/ pelvic fracture, and asked if the patient should be transferred to a PTC. Associations between parameters and physician demographics in the decision to transfer were examined. RESULTS: One hundred seven and 94 surveys were completed at L3TCs and PTCs, respectively. Parameters associated with decision to transfer: pelvic and GI tract injuries, GCS < 12, and age < 4 years. L3TCs were significantly less likely vs. PTCs to recommend transfer with femur fracture, solid organ / GI injury, or a GCS of <13. Increasing town size, access to an experienced surgeon, and formal training in emergency medicine among L3TC physicians were associated with a decision not to transfer. CONCLUSIONS: Injuries requiring potential surgery or critical care influenced the decision to transfer. For cases with lesser severity or older ages, input of L3TCs on developing triage criteria is vital to allow families to stay in their home communities while ensuring optimal clinical outcomes. TYPE OF STUDY: Prospective Cross Sectional Survey. LEVEL OF EVIDENCE: Level III.