Effect of fertility health awareness strategies on fertility knowledge and childbearing in young married couples (FertStart): study protocol for an effectiveness-implementation hybrid type I multicentre three-arm parallel group open-label randomised clinical trial.

INTRODUCTION: Birth rates have been declining in many advanced societies including Singapore. We designed two interventions with vastly different resource requirements, which include fertility education, personalised fertility information and a behavioural change component targeting modifiable psychological constructs to modify fertility awareness and childbearing intentions. We aim to evaluate the effect of these two interventions on knowledge, attitudes and practice around childbearing compared with a control group among young married couples in Singapore and understand the implementation factors in the setting of an effectiveness-implementation hybrid type 1 three-arm randomised trial. METHODS AND ANALYSIS: We will randomise 1200 young married couples to no intervention (control), Fertility Health Screening group (FHS) or Fertility Awareness Tools (FAT) in a 7:5:5 ratio. Couples in FHS will undergo an anti-Mullerian hormone test and semen analysis, a doctor's consultation to explain the results and standardised reproductive counselling by a trained nurse. Couples in FAT will watch a standardised video, complete an adapted fertility status awareness (FertiSTAT) tool and receive an educational brochure. The attitudes, fertility knowledge and efforts to achieve pregnancy of all couples will be assessed at baseline and 6 months post-randomisation. Birth statistics will be tracked using administrative records at 2 and 3 years. The primary outcome is the change in the woman's self-reported intended age at first birth between baseline and 6 months post-randomisation. In addition, implementation outcomes and cost-effectiveness of the two interventions will be assessed. ETHICS AND DISSEMINATION: This study has been reviewed and approved by the Centralized Institutional Review Board of SingHealth (2019/2095). Study results will be reported to the study funder and there are plans to disseminate them in scientific conferences and publications, where authorship will be determined by the International Committee of Medical Journal Editors guidelines. TRIAL REGISTRATION NUMBER: NCT04647136; ClinicalTrails.gov Identifier.

Patient, staff empowerment and hand hygiene bundle improved and sustained hand hygiene in hospital wards.

AIM: We piloted a hand hygiene (HH) project in a ward, focusing on World Health Organization moments 1 and 4. Our aim was to design highly reliable interventions to achieve >90% compliance. METHODS: Baseline HH compliance was 57 and 67% for moments 1, 4, respectively, in 2015. After the pilot ward showed sustained improvement, we launched the 'HH bundle' throughout the hospital. This included: (i) appointment of HH champions; (ii) verbal/visual bedside reminders; (iii) patient empowerment; (iv) hand moisturisers; (v) tagging near-empty handrub (HR) bottles. Other hospital-wide initiatives included: (vi) Smartphone application for auditing; (vii) 'Speak up for Patient Safety' Campaign in 2017 for staff empowerment; (viii) making HH a key performance indicator. RESULTS: Overall HH compliance increased from a baseline median of 79.6-92.6% in end-2019. Moments 1 and 4 improved from 71 to 92.7% and from 77.6 to 93.2%, respectively. Combined HR and hand wash consumption increased from a baseline median of 82.6 ml/patient day (PD) to 109.2 mL/PD. Health-care-associated rotavirus infections decreased from a baseline median of 4.5 per 10 000 PDs to 1.5 per 10 000 PDs over time. CONCLUSIONS: The 'HH Bundle' of appointing HH champions, active reminders and feedback, patient education and empowerment, availability of hand moisturisers, tagging near-empty hand rub bottles together with hospital-wide initiatives including financial incentives and the 'Speak Up for Patient Safety' campaign successfully improved the overall HH compliance to >90%. These interventions were highly reliable, sustained over 4 years and also reduced health-care-associated rotavirus infection rates.

Repair Method for Complete High Ulnar Nerve Injury Based on Nerve Magnified Regeneration.

PURPOSE: Complete high ulnar nerve injury can cause serious sequelae, including residual sensation and loss of movement and especially dysfunction of the intrinsic muscles of the hand. As a solution to treat complete high ulnar nerve injury, we proposed a new repair method for ulnar nerve injury based on nerve-magnified regeneration. METHODS: Twenty-two patients with complete division of the ulnar nerve at a high level who were treated from May 2013 to December 2016 were divided into two groups. The proposed repair method for complete high ulnar nerve injury was performed in group I (11 patients), while the traditional repair method, ie, repair of the original injury site of the ulnar nerve, was used in group II (11 patients). RESULTS: The results showed no significant difference in the mean sensory scores assigned by the Highet-Zachary scheme (the Highet Scale) between the two groups. The mean Highet Scale score of muscle strength for the first dorsal interosseus muscle was significantly better in group I than that in group II (p=0.010). In group I, 10 of 11 patients were graded as M4 or M5. Grip strength, pinch strength, and the Disabilities of the Arm, Shoulder, and Hand (DASH) score were significantly better in group I than those in group II (p<0.01). CONCLUSION: Therefore, this method for complete high ulnar nerve injury based on nerve-magnified regeneration can shorten the path of motor nerve regeneration, effectively reduce atrophy of the intrinsic muscles of the hand, and provide better hand function.

The 2019 WACEM Expert Document on the Framework for Setting up a Simulation Centre.

Almost every institution and academic medical center has its own simulation center today. It seems to have become a prerequisite and is incorporated into the guidelines of setting up new centers as well as in the upgrading and enhancement plans of existing institutions. In considering this, it is critical to consider the needs and demands of the healthcare population and staff the center will be serving. Setting up a simulation center is not an endeavor to be undertaken lightly. It entails a sustainable commitment in terms of political will, professional, educational and financial commitments. On the other hand, setting up a simulation center can be the most worthwhile and rewarding experience if the objectives and goals are met and effective learning occurs. The latter is an important element to be considered in the step toward nurturing an effective healthcare practitioner. In this paper, the principle author, who is the Director of the SingHealth Duke NUS Institute of Medical Simulation (SIMS) in Singapore, shares her views and experience of leading a world-class simulation facility. She has been involved in SIMS from its conception and is a strong advocate of medical education and lifelong learning. At the end of this paper, she shares a Checklist which puts together all the important considerations for anyone or any institution what is looking at setting up a simulation facility, a simulation-based training program, or even upgrading and upscaling their current simulation centre.

[Relationship between radiographic parameters and clinical outcomes of elderly patients with distal radius fractures].

OBJECTIVE: To analyze the relationship between radiographic parameters and clinical outcomes of patients with distal radius fractures in elderly patients following conservative treatment, and find the important radiographic parameters with distal radius fractures in elderly patients. METHODS: From May 2012 to May 2015, a retrospective analysis was performed of 45 elderly patients with distal radius fractures treated by conservative treatment, which including 17 males and 28 females with an average age of 64.49 years old from 60 to 89 years old. The imaging parameters were measured and the clinical efficacy was evaluated. The imaging parameters on the standard wrist joint X-ray picture were measured including metacarpal angle, the radius height, the ulna variation, the ulnar angle, and so on. The clinical effect of wrist joint was evaluated by Dienst score standard. Multiple factor linear regression was used to analyze the relationship between the image parameters and the clinical efficacy. RESULTS: All patients were followed up for 12 to 24 months with an average of 17.6 months. All fractures of the distal radius were healed. According to the Dienst evaluation, at the final follow-up the result was excellent in 27 cases, good in 10 cases, fair in 6 cases and poor in 2 cases. There was a significant correlation between the height of the radius, the angle of the palmar and the variation of the ulna and the function of the wrist joint in the imaging parameters. When the radius height more than 8.12 mm, the palmar angle more than -1.64 degree and the ulna variant less than 4.05 mm, the result of Dienst function was better. CONCLUSIONS: The imaging parameters such as the radius height, the palmar angle and the ulna variation are related to the recovery of the clinical efficacy of the distal radius fractures in the elderly. The most important parameter is the radius height, which reminds the surgeon to pay special attention to the reduction of the radius fracture in the elderly.

[Vascular crisis after multiple tissue transplantation for thumb and other finger reconstruction by toe-to-hand transfer].

Objective: To explore the causes of vascular crisis after thumb and other finger reconstruction by toe-to-hand transfer and effective treatment methods so as to improve the survival rate of transplanted tissues. Methods: Between February 2012 and October 2015, 59 cases of thumb and other finger defects were repaired with different hallux nail flaps with the same vascular pedicle flap to reconstruct thumb and other fingers and repair skin defect. The donor site was repaired by a perforator flap. A total of 197 free tissues were involved. There were 46 males and 13 females with the average age of 30.6 years (range, 18-42 years). Vascular crisis occurred in 21 free tissues (10.7%) of 17 patients, including 9 arterial crisis (4.6%) of 8 cases, and 12 venous crisis (6.1%) of 10 cases. Conservative treatment was performed first; in 8 free tissues of 7 cases after failure of conservative treatment, anastomotic thrombosis was found in 5 free tissues of 4 cases, twisted vascular pedicle in 1 free tissue of 1 case, surrounding hematoma in 1 free tissue of 1 case, and anastomotic thrombosis associated with hematoma in 1 free tissue of 1 case, which underwent clearing hematoma, resecting embolization, regulating vascular tension, re-anastomosis or vascular transplantation. Results: In 8 cases of arterial crisis, 5 free tissues of 5 cases survived after conservative treatment; partial necrosis occurred in 1 free tissue (1 case) of 4 free tissues (3 cases) undergoing surgical exploration. In 10 cases of venous crisis, 1 free tissue necrosis and 1 free tissue partial necrosis occurred in 8 free tissues (6 cases) undergoing conservative treatment; partial necrosis occurred in 1 free tissue of 4 free tissues (4 cases) undergoing surgical exploration. Free flap and skin graft were performed on 2 free tissues of 4 cases having flap necrosis respectively. Conclusion: Vascular crisis is complex and harmful to survival of transplanted tissue in reconstruction of the thumb and other fingers. Immediate intervention is helpful to obtain a higher survival rate.

Predictive displays for a process-control schematic interface.

OBJECTIVE: Our objective was to examine the extent to which increasing precision of predictive (rate of change) information in process control will improve performance on a simulated process-control task. BACKGROUND: Predictive displays have been found to be useful in process control (as well as aviation and maritime industries). However, authors of prior research have not examined the extent to which predictive value is increased by increasing predictor resolution, nor has such research tied potential improvements to changes in process control strategy. METHOD: Fifty nonprofessional participants each controlled a simulated chemical mixture process (honey mixer simulation) that simulated the operations found in process control. Participants in each of five groups controlled with either no predictor or a predictor ranging in the resolution of prediction of the process. RESULTS: Increasing detail resolution generally increased the benefit of prediction over the control condition although not monotonically so. The best overall performance, combining quality and predictive ability, was obtained by the display of intermediate resolution. The two displays with the lowest resolution were clearly inferior. CONCLUSION: Predictors with higher resolution are of value but may trade off enhanced sensitivity to variable change (lower-resolution discrete state predictor) with smoother control action (higher-resolution continuous predictors). APPLICATION: The research provides guidelines to the process-control industry regarding displays that can most improve operator performance.

[Therapeutic effects of treatment of posterior malleolar fractures with medial-extension type through posterioromedial and posteriorlateral incision].

OBJECTIVE: To explore clinical outcomes of posterior malleolar fractures with medial-extension type through posterioromedial and posteriorlateral incision. METHODS: From January 2008 to January 2011,25 patients with posterior malleolar fractures with medial-extension type were treated by hollow lag screw. Among them, 15 patients were treated through posteromedial incision,including 9 males and 6 females,aged from 21 to 67 years old with an average of 48.1 +/- 1.3; there were 5 cases with type A, 6 cases with type B and 4 cases with type C,according to Denis-Weber classification. Ten patients were treated by through posterior-lateral incision,including 6 males and 4 females, aged from 23 to 64 years old with an average of 46.9 +/- 1.5; there were 3 cases with type A, 5 cases with type B and 2 cases with type C,according to Denis-Weber classification. Operation time, blood loss, length of incision, times of X-ray exposure and complications of two groups were recorded and compared, Baird-Jackson effective evaluation were applied for evaluate clinical outcomes. RESULTS: All patients were followed up from 12 to 49 months with an average of 20.6 months. There were significant differences in operation time, blood loss, times of X-ray exposure and complications between two group (P < 0.05). While there was no obvious meaning in clinical outcomes between two groups (P > 0.05). CONCLUSION: Treating posterior malleolar fractures with medial-extension type through posteromedial approach can expose and fix fracture under direct vision, has advantages of shorter operation time, less X-ray exposure and blood loss, is a good choice of surgical approach.

[Comparing clinical effects of titanic elastic nail and locking compression pine fixation in treating subtrochanteric fractures in older children].

OBJECTIVE: To explore optimal choice of surgical treatment for subtrochanteric fractures in older children. METHODS: A retrospective study of 36 older children with subtrochanteric fractures was performed between January 2010 and January 2012. Among them, 18 patients (11 males and 7 females) aged from 7 to 13 years old with an average of 9.4 were treated with titanic elastic nail (TEN) fixation, 4 cases were Type II A, 3 cases were II B, 2 cases were II C, 4 cases were III A, 3 cases were III B according to Seinsheimer classification. Eighteen patients (10 males and 8 females) aged was from 8 to 13 years with an average of 9.6 were treated with locking compression pine (LCP) fixation, and 3 cases were Type II A, 4 cases were II B, 3 cases were II C, 4 cases were IIIA, 2 cases were III B. Fracture healing time, postoperative complications (including wound infection, failure and breakage of internal fixtion, deformities of angular on the sagittal view, deformities of coxa vara) and recovery of hip joint function were observed and recorded. RESULTS: All children were followed up from 15 to 36 months with an average of 21. Fracture were all healed, the time ranged from 7 to 16 weeks (mean 9.5). Three cases in TEN group occurred mild deformities of angular on the sagittal view, 3 cases occurred deformities of coxa vara and 2 cases occurred limb shortening; while 1 case occurred mild deformities of angular on the sagittal view, and no deformities of coxa vara and limb shortening occurred in LCP group. No early close of epiphyseal injury, avascular necrosis of femoral head occurred. Clinical efficacy were evaluated by Sanders standard, 14 cases got excellent results, 3 cases were moderate in LCP group, while 9 cases in excellent, 4 in moderate in TEN group. There were no significant differences between two group in recovery of hip joint function and complications. CONCLUSION: For the treatment of subtrochanteric fractures in older children,the efficacy of LCP fixation is better than that of TFN fixation, which has advantages of reliable fixation, and less complications.

[Comparison of the effect between early anatomical open reduction, internal fixation and closed reduction, internal fixation for treatment of children displaced femoral neck fracture].

OBJECTIVE: To compared the effect between early anatomical open reduction, internal fixation (ORIF) and closed reduction, internal fixation (CRIF) for treatment of children displaced femoral neck fracture. METHODS: From March 2006 to May 2010,34 children with displaced femoral neck fractures were reviewed retrospectively. These patients were divided into two groups. Among them, 19 cases were treated by open reduction and internal fixation (ORIF) as group A, included 11 males and 8 females with an average age of (8.1 +/- 1.3), the other 15 cases were treated by closed reduction and internal fixation (CRIF) as group B, included 9 males and 6 females with an average age of (7.9 +/- 1.5). Complications were observed and the short term effectiveness was evaluated by Ratliff standard. RESULTS: All children were followed-up from 1 to 3 years (means 1.2 years). All fractures were healed. There was statistical different in the curative effects between the two groups (Z=2.389, P= 0.017). The incidence of complications in two groups had statistical different (P=0.046). CONCLUSION: The early ORIF could get better reduction with fewer complications than CRIF in fractures of the displaced femoral neck in children in Delbet type-II and type-III, therefore, ORIF should be considered.

[Treatment strategy of double disruption of the superior shoulder suspensor complex (SSSC)].

OBJECTIVE: To discuss efficacy of the surgical treatment strategy of double disruption of the superior shoulder suspensor complex (SSSC). METHODS: The data of 15 patients with double disruption of the SSSC were retrospectively analyzed from January 2008 to December 2009. There were 11 males and 4 females, with an average age of 45.1 years (ranged, 19 to 60). Of them, 8 patients were treated with surgery and 7 patients with conservative treatment. The short-term effectiveness was evaluated according to Constant-Murley scoring system. RESULTS: All patients were followed up for 7 to 24 months with an average of 14.4 months. All fractures healed with a mean time of 12.3 weeks (ranged, 9 to 12). At final follow-up, the Constant-Murley scores with patients of surgical treatment was (92.37 +/- 1.99), and patients of conservative treatment was (55.52 +/- 1.29). CONCLUSION: Surgical treatment can restore the integrality of SSSC, in favour of stability between upper limb and trunk.