The effect of regional anesthesia blocks on post-operative pain after ambulatory orthopedic trauma surgery.

PURPOSE: To determine if regional anesthesia had added benefit to general anesthesia, with or without local anesthesia, in controlling post-operative pain in outpatient orthopedic trauma surgery. METHODS: A retrospective review was performed of prospectively gathered data on 71 patients undergoing outpatient orthopedic trauma surgery. All patients received general anesthesia and an addition 52 patients received additional regional anesthesia. Regional vs. no regional anesthesia groups were compared in terms of post-anesthesia care unit (PACU) pain visual analog scores (VAS), PACU length of stay (LOS), opioid use, and pain control at two weeks. RESULTS: The regional anesthesia group not differ in demographics or proportion of patients receiving local anesthesia, but was less likely to be undergoing major procedures (13% vs. 37%, proportional difference (PD) - 23%; 95% confidence interval (CI) - 46% to - 0.4%). There were no detectable differences in PACU opioid requirements (median difference (MD) - 7.5 mg, CI - 8 to 0), PACU LOS (MD - 13 min, CI - 63 to 24), discharge pain VAS (MD 0, CI - 1 to 1), post-discharge pain VAS (MD 0, CI - 1 to 1), opioid refills (PD - 6%, CI - 31% to 18%), or patient-perceived pain control (PD - 24%, CI - 41% to 0%). On multivariate analysis, regional anesthesia was the only variable negatively associated with patient-perceived pain control at two weeks (Odds Ratio 0.15; 95% CI 0.03 to 0.8). CONCLUSIONS: Regional anesthesia did not improve post-operative opioid requirements, PACU LOS, or patient-reported pain in the immediate or short-term post-operative period.

The effect of the orthopaedic trauma association's (OTA) pain management guidelines on opioid prescriptions, pain control, and refills in outpatient orthopaedic trauma surgery.

PURPOSE: To determine the effect of the Orthopaedic Trauma Association (OTA) pain management guidelines for acute musculoskeletal injuries on opioid prescription sizes, pain control, and refills. METHODS: A prospective cohort study was performed at an academic urban level 1 trauma center. 90 patients undergoing outpatient orthopaedic trauma surgery were enrolled before and after the implementation of the OTA pain management guidelines. Adherence to guidelines, pain visual analog scale, and refills were recorded postoperatively and at the 2- and 6-week follow-up visit. RESULTS: After implementation of the guidelines, the number of patients receiving oxycodone decreased from 100 to 27%, with these patients receiving the less potent hydrocodone, instead. The discharge morphine equivalent dose (MED) decreased from a median (interquartile range) of 225 (169-300) to 140 mg (140-210) (p < 0.001). More patients required refills in the guidelines group (42% vs. 20%), resulting in no difference in total MED prescribed (210 (140-280) vs. 225 (169-307)). Adherence to the guidelines occurred in 66% of patients. As-treated analysis of patients with adherent and non-adherent prescriptions found no detectable difference in pain control, number of opioid pills used, or refills at the 2-week and 6-week follow-up. CONCLUSIONS: In the midst of a national opioid crisis, adoption of the OTA's pain management guidelines for orthopaedic trauma surgery warrants further research to determine if it's implementation can reduce the size, variability, and duration of opioid prescriptions. LEVEL OF EVIDENCE: Level II, prospective cohort.

Sexual assault: women's voices on the health impacts of not being believed by police.

BACKGROUND: Sexual assault is a prevalent crime against women globally with known negative effects on health. Recent media reports in Canada indicate that many sexual assault reports are not believed by police. Negative reporting experiences of sexual assault have been associated with secondary victimization and trauma among survivors. However, little is known about the impact that being sexually assaulted and not believed by police has on a survivor's health and well-being. The purpose of this study was to explore women's experiences of not being believed by police after sexual assault and their perceived impact on health. METHODS: We conducted open-ended and semi-structured interviews with 23 sexual assault survivors who were sexually assaulted and not believed by police. The interviews explored the self-reported health impacts of not being believed by police and were conducted from April to July, 2019. All interviews were audio-recorded, transcribed, and entered into NVIVO for analysis. Data were analyzed using Colaizzi's analytic method. RESULTS: Analysis revealed three salient themes regarding the health and social impact of not being believed by police on survivors of sexual assault: (1) Broken Expectations which resulted in loss of trust and secondary victimization, (2) Loss of Self, and (3) Cumulative Health and Social Effects. The findings showed that not being believed by police resulted in additional mental and social burdens beyond that of the sexual assault. Many survivors felt further victimized by police at a time when they needed support, leading to the use taking of alcohol and/or drugs as a coping strategy. CONCLUSION: Reporting a sexual assault and not being believed by police has negative health outcomes for survivors. Improving the disclosure experience is needed to mitigate the negative health and social impacts and promote healing. This is important for police, health, and social service providers who receive sexual assault disclosures and may be able to positively influence the reporting experience and overall health effects.

Initial management of humeral shaft fractures with functional splints versus coaptation splints.

PURPOSE: Humerus shaft fractures are commonly acutely immobilized with coaptation splints (CS), which can be difficult to apply and poorly tolerated by the patient. Functional splints (FS), which work on the same principle as functional braces, are an alternative to CS. The purpose of this study was to directly compare CS and FS in terms of application and fracture reduction. METHODS: A retrospective review identified humeral shaft fractures managed nonoperatively with initial immobilization in a FS (n = 19) versus a CS (n = 15). In addition, 13 residents completed a blinded survey on splint application. RESULTS: The FS and CS groups did not differ in initial fracture angulation and translation on anteroposterior (AP) and lateral radiographs. Post-splint application, there was no clinically relevant difference in fracture angulation/translation between groups, and this persisted at the subsequent follow-up visit. All residents reported that the FS was easier to apply and took less time. CONCLUSION: This study results demonstrated the FS results in similar reductions in humeral shaft fractures as CS. A survey of residents found that the FS was easier to apply, took less time, and was better tolerated by patients. Subsequently, we prefer the FS over the CS for the acute management of humeral shaft fractures.

Just add water? Chlorhexidine's antimicrobial properties are minimally affected by dilution in saline compared to water.

BACKGROUND: Dilute chlorhexidine gluconate (CHG) in sterile water is an antiseptic solution approved for intraoperative wound irrigation by the United States Food and Drug Administration. In practice, however, CHG is commonly diluted with normal saline, which can result in its precipitation potentially reducing the antimicrobial effect. The purpose of this study was to determine if the antimicrobial properties of CHG are reduced after dilution with normal saline compared to sterile water. MATERIALS AND METHODS: Sterile paper disks were placed into undiluted 4% CHG (positive control), 0.05% CHG in sterile water, 0.05% CHG in normal saline, or normal saline alone (negative control) and then placed in triplicate onto the agar plates inoculated with Staphylococcus aureus. After incubating at 37 °C for 24 h, the diameter of the zone of inhibition around each disk was measured. RESULTS: The mean zone of inhibition for 4% CHG, 0.05% CHG in sterile water, 0.05% CHG in normal saline, and normal saline alone was 24 ± 0.6 mm, 16 ± 0.9 mm, 14 ± 0.5 mm, and 0 ± 0 mm, respectively (p < 0.01). The zone of inhibition for dilute CHG in normal saline was on average 2.5 mm less (95% CI 1.7-3.2 mm) than that of CHG in sterile water. CONCLUSIONS: Dilute CHG in normal saline, versus sterile water, retained its antimicrobial activity with a small reduction in the zone of inhibition. Surgeons and scientists should be aware of the interaction between normal saline and CHG. Future scientific studies need to control for what solution is used for dilution.

The effect of surgical pain severity, preoperative opioid use and patient characteristics on postoperative opioid prescriptions and refills in orthopedic surgery.

BACKGROUND: Excessive opioid prescriptions after orthopedic surgery are common. The purpose of this study was to examine the association between surgical severity, preoperative opioid use and patient characteristics with postoperative opioid prescriptions and refills. METHODS: Seventy-nine patients undergoing orthopedic surgeries were reviewed. Surgical pain severity was categorized as mild (n = 25), moderate (n = 26) and severe (n = 28). Patients were also categorized as opioid naïve (n = 57), experienced (n = 16) and tolerant (n = 6). Postoperative and refill prescriptions were reviewed to determine morphine equivalent dose (MED) prescribed. RESULTS: Mild, moderate and severe pain surgeries received a median (interquartile range) equivalent of 20 (0, 30), 53 (33, 80) and 60 (45, 80) oxycodone 5 mg tablets, respectively. Excessive opioid prescriptions (> 400 MED) were given to 37 (46%) patients. There was no difference in the total discharge MED between moderate and severe pain surgeries or between opioid naïve and opioid-experienced patients (p > 0.05). Variables associated with excessive postoperative opioid prescriptions on multivariate analysis-included severe pain surgery (odds ratio 7.7, 95% confidence interval 2 to 25; p < 0.01) and anesthetic block (odds ratio 4.5, 95% confidence interval 1.4 to 14; p < 0.01). Variables associated with opioid refill on multivariate analysis included an American Society of Anesthiologists Physical Status (ASA) score > I (odds ratio 11, 95% confidence interval: 1.3 to 92; p < 0.01) and preoperative pain VAS (odds ratio 1.2, 95% confidence interval 1.01 to 1.4; p = 0.02). CONCLUSION: The adoption of opioid prescription guidelines is warranted to differentiate between surgical severities and decrease the range and size of postoperative opioid prescriptions.

Screws are at a safe distance from critical structures after superior plate fixation of clavicle fractures.

INTRODUCTION: Injuries to the critical structures underlying the clavicle are possible during open reduction and internal fixation (ORIF) and afterward secondary to prominent screws. The purpose of this study was to identify patients who received chest computerized tomography (CT) scans after clavicle ORIF to evaluate the distance between the screws and the subclavian vessels. METHODS: A retrospective review was performed at a single level-one trauma center. Nineteen patients with chest CT scans after superior plate fixation were included. Coronal CT reconstructions were analyzed to determine distances between the subclavian vessels and screw tips along with the prominence of the screws. Vessels within 15 mm of the screw were considered at risk. RESULTS: None of the screws (0/142) were within 15 mm of the subclavian vessels. Average screw prominence was 1.3 ± 1 mm (range, 0-3.6 mm). One of the 19 patients had a complication, a re-fracture requiring revision ORIF. The remaining 18 patients had no complications, including neurovascular or pulmonary, at the last follow-up. CONCLUSIONS: None of the screws were excessively prominent or within 15 mm of the subclavian vessels. Attentive superior plate fixation of the clavicle with screws is a safe technique. LEVEL OF EVIDENCE: Level IV, case series.

Exploring the use of fact-based and story-based learning materials for HIV/STI prevention and sexual health promotion with South Asian women in Toronto, Canada.

Story-based learning is well recognized as an effective strategy for adult health education. However, there is a scarcity of research on story-based health education among women in South Asian diasporic communities. To address this gap, we undertook a pilot study in Toronto to explore how South Asian women respond to the use of fact-based and story-based materials for HIV/STI prevention. A total of 78 women were recruited from across the city. We engaged nearly half of the women (n=40) using fact sheets on HIV/STIs, and the remainder (n=38) using stories written by South Asian women on HIV/STIs. Surveys and focus groups were used to explore participants' responses in terms of knowledge, attitudes and perspectives. Results indicated that both approaches were effective in increasing participants' knowledge of HIV/STIs. Participants in the fact-based sessions tended to distance themselves from the idea of personal HIV/STI risks. Participants in the story-based groups were emotionally engaged, expressing personal commitments to take a stand against HIV stigma. In summary, within-culture stories are potentially effective tools that enable women to make sense of their own life situations and contextual vulnerabilities. Story-based materials are useful for breaking the silence of taboo topics, addressing stigma and discrimination and raising awareness about collective empowerment.

Decolonizing Scoping Review Methodologies for Literature With, for, and by Indigenous Peoples and the African Diaspora: Dialoguing With the Tensions.

This article summarizes our deepened understanding of decolonizing research with, for, and by Indigenous peoples and peoples of African descent that emerged from conducting a scoping review of the methodological literature and reflecting on our review process. Although our review identified decolonizing methodologies as a promising approach, we questioned if our scoping review process engaged in decolonizing knowing. To unpack the epistemological tensions between decolonizing knowing and Western ways of doing scoping reviews, we engaged in individual and collective reflective processes- dialoguing with the tensions-moving from individual immersion in the literature to transformative dialogues among the team. In reflecting upon our tensions with the scoping review process, themes that emerged included (a) ontological/epistemological disjunctures, (b) tensions with concepts and language, and (c) relationships with the literature and beyond. This reflexive process provides valuable insight into ways in which review methods might be made a decolonizing research experience.

Stigma, HIV and health: a qualitative synthesis.

BACKGROUND: HIV-related stigma continues to negatively impact the health and well-being of people living with HIV, with deleterious effects on their care, treatment and quality of life. A growing body of qualitative research has documented the relationship between HIV-related stigma and health. This review aims to synthesize qualitative evidence that explored the intersections of stigma and health for people with HIV. METHODS: A thematic summary was conducted that was guided by the qualitative metasummary technique developed by Sandelowski and Barraso. Literature searches yielded 8,622 references of which 55 qualitative studies were identified that illustrated HIV-related stigma in the context of health. RESULTS: The metasummary classified qualitative findings into three overarching categories: conceptualizing stigma which identified key dimensions of HIV-related stigma; experiencing stigma which highlighted experiences of stigma in the health context, and managing stigma which described ways in which stigma is avoided or addressed. To better illustrate these connections, the qualitative literature was summarized into the following themes: stigma within health care settings, the role of stigma in caring for one's health, and strategies to address HIV-related stigma in the health context. A number of health care practices were identified--some rooted in institutional practices, others shaped by personal perceptions held by practitioners--that could be stigmatizing or discriminatory towards people with HIV. There existed interconnections between enacted stigma and felt stigma that influenced health care utilization, treatment adherence, and overall health and well-being of people with HIV. Intersectional stigma also emerged as instrumental in the stigma experiences of people living with HIV. A number of strategies to address stigma were identified including social support, education, self-efficacy, resilience activities, and advocacy. CONCLUSION: This review of the qualitative evidence indicates that HIV-related stigma within health contexts is a broad social phenomenon that manifests within multiple social spheres, including health care environments. Findings from this review indicate that future stigma research should consider the social structures and societal practices--within and outside of health care environments--that perpetuate and reinforce stigma and discrimination towards people with HIV.

Evidence informing the intersection of HIV, aging and health: a scoping review.

The growing number of people over age 50 with HIV requires research, policy, and practice to develop a more comprehensive understanding of the health consequences of HIV in older individuals. We conducted a scoping review of peer-reviewed and grey literature published since 1996 to explore the impacts of aging on the health of older people with HIV (50 years or older). We included 209 studies (two systematic reviews, 174 quantitative studies, 28 qualitative studies, and five mixed methods studies). Health topics addressed include: HIV- and aging-related comorbidities, disease progression, neurocognitive functioning, mental health conditions, psychological well-being, social supports, stigma, antiretroviral adherence, health care utilization/access, and sexual risk behaviour. We recommend that future research takes a broader view of health, looks at aging from a strength-based perspective and examines the issue using diverse perspectives (i.e., geographic location, multiple methods, time of diagnosis, time on antiretroviral therapy (ART), demographic diversity).

The psychological and health consequences of caring for a spouse with dementia: a critical comparison of husbands and wives.

Caring for someone with dementia can be demanding, particularly for spouses living with the care recipient. The main goal of this study was to clarify differences in the experience of caregivers who were husbands and wives with respect to burden, health, healthy behaviors, presence of difficult care recipient behaviors, social supports, and the quality of the premorbid relationship. The results of this study support research demonstrating a difference between the caregiving experiences of women and men. It is becoming increasingly apparent that female gender is a marker that places them at increased risk of high burden and less support.

The Internal Joint Stabilizer of the Elbow: A Systematic Review of the Clinical and Biomechanical Evidence.

Purpose: The goal of surgical management for unstable elbow injuries is the restoration of joint concentricity and stability. After internal fixation, concerns may exist regarding instability or durability of the fixation construct. Historically, these scenarios were treated with options such as transarticular pinning or external fixation. Recently, an internal joint stabilizer (IJS) that allows postoperative mobilization was introduced. Our objective was to systematically review the literature to aggregate the clinical and biomechanical evidence for the IJS of the elbow. Methods: A systematic review of the PubMed and Google Scholar databases was performed, following the PRISMA guidelines. The search results were narrowed from 2015 through 2023 to coincide with the inception of the device being reviewed. Results: A total of nine retrospective reports on the IJS (N = 171) cases at a mean follow-up of 10.8 months were included. The pooled rate of implant failure was 4.4%, and recurrent instability was 4.1%. Additionally, the we included seven case reports and two biomechanical reports. Conclusions: The aggregate literature describes satisfactory clinical outcomes with low rates of recurrent instability and device failure for the IJS of the elbow. The limited biomechanical investigations conclude efficacy for stability profiles. Clinical relevance: Across a spectrum of unstable elbow cases, the IJS prevented recurrent instability during the early postoperative period. Notably, the device requires an additional procedure for removal, and the long-term impact of the retained devices is currently unclear.

Intramedullary Nail Fixation for Metacarpal Fracture: A Case Report and Review of the Clinical and Biomechanical Evidence.

We present two cases of complex metacarpal fractures treated with an intramedullary locking nail. This is an emerging fixation method that minimizes tissue insult, provides sufficient stability, and allows early mobilization. Locking nails accommodate the capture of fractured fragments in complex unstable patterns and provide longitudinal and rotational stability. The described intrafocal technique is intended to improve coaxial placement of the wire into the medullary canal.

Meaningful inclusion of people living with HIV as a model for workplace policies: Key findings from the project PEER study.

BACKGROUND: As a large number of people live with HIV, it is worthwhile to examine the integration of this group in the workplace. OBJECTIVE: To investigate how the operationalization of GIPA/MEPA supports workplace policies and practices for PLHIV. The study aims to explore what is being offered to support PLHIV in community-based agencies and what can be done to enhance the offerings. METHODS: For this community-based research, 2 bilingual online surveys were sent to 150 Canadian organizations that work closely with PLHIV or offer support to them. One of the surveys was for Executive Directors of these organizations while the other was sent to peers; i.e. PLHIV whose job is to offer services to PLHIV. Questions in the surveys varied between open-ended, binary, and Likert. RESULTS: GIPA/MEPA are implemented in most organizations and Executive Directors affirmed that PLHIV and their impacts on the workplace are valued. There is a consensus among Executive Directors that formal support is provided but most respondents argued that this support is not specific for PLHIV. More than half of respondents were either unaware or uncertain about the existence of informal support. Peer-employees claimed that one of the challenges of disclosing HIV to receive peer support is that they may face stigma. CONCLUSION: The application of GIPA/MEPA results in positive outcomes in the workplace. The study emphasizes the need to facilitate access to informal support.

Impact of Children's Presence on Police Responses to Domestic Violence Call Situations.

The link between children exposed to intimate partner violence (IPV) and child maltreatment is well established; however, less is known about the impact children's presence may have on domestic violence disputes. This study investigated the role of children's presence in IPV police calls using data (N = 2709) from supplementary reports provided by an Ontario, Canada police force, one-third of which led to criminal charges (n = 909). When children were present: charges were less likely to be laid; the accused's emotional state was more likely to be rated by police as calm and the accused was less likely to be identified as using alcohol and/or drugs at the time of the call; and victim support interventions were more likely to be offered and accepted. Findings were considered in the context of when charges were laid versus not laid. Implications for police and support service interventions were discussed.

Association of returning to work with better health in working-aged adults: a systematic review.

OBJECTIVES: We systematically reviewed the literature on the impact of returning to work on health among working-aged adults. METHODS: We searched 6 electronic databases in 2005. We selected longitudinal studies that documented a transition from unemployment to employment and included a comparison group. Two reviewers independently appraised the retrieved literature for potential relevance and methodological quality. RESULTS: Eighteen studies met our inclusion criteria, including 1 randomized controlled trial. Fifteen studies revealed a beneficial effect of returning to work on health, either demonstrating a significant improvement in health after reemployment or a significant decline in health attributed to continued unemployment. We also found evidence for health selection, suggesting that poor health interferes with people's ability to go back to work. Some evidence suggested that earlier reemployment may be associated with better health. CONCLUSIONS: Beneficial health effects of returning to work have been documented in a variety of populations, times, and settings. Return-to-work programs may improve not only financial situations but also health.

Sexual Assault: Indigenous Women's Experiences of Not Being Believed by the Police.

Rates of sexual victimization among Indigenous women are 3 times higher when compared with non-Indigenous women. The purpose of this secondary data analysis was to explore the experiences and recommendations of Indigenous women who reported sexual assault to the police and were not believed. This qualitative study of the experiences of 11 Indigenous women reflects four themes. The women experienced (a) victimization across the lifespan, (b) violent sexual assault, (c) dismissal by police, and (d) survival and resilience. These women were determined to voice their experience and make recommendations for change in the way police respond to sexual assault.

Unfounded Sexual Assault: Women's Experiences of Not Being Believed by the Police.

One in four women will experience sexual assault in their lifetime. Although less than 5% of sexual assaults are reported to law enforcement, one in five cases reported to police are deemed baseless (by police) and therefore coded as "unfounded." Police officers are in a unique position to act as gatekeepers for justice in sexual assault cases, given their responsibility to investigate sexual assault reports. However, high rates of unfounded sexual assaults reveal that dismissing sexual violence has become common practice amongst the police. Much of the research on unfounded sexual assault is based on police perceptions of the sexual assault, as indicated in police reports. Women's perspectives about their experiences with police are not represented in research. This qualitative study explored women's experiences when their sexual assault report was disbelieved by the police. Data collection included open-ended and semi-structured interviews with 23 sexual assault survivors. Interviews covered four areas including the sexual assault, the experience with the police, the experience of not being believed, and the impact on their health and well-being. Interviews were audio-recorded, transcribed, and entered into NVIVO for analysis. Data were analyzed using Colaizzi's analytic method, resulting in the identification of four themes, including, (a) vulnerability, (b) drug and alcohol use during the assault, (c) police insensitivity, and (d) police process. The women in this study who experienced a sexual assault and reported the assault to police were hopeful that police would help them and justice would be served. Instead, these women were faced with insensitivity, blaming questions, lack of investigation, and lack of follow-up from the police, all of which contributed to not being believed by the institutions designed to protect them. The findings from this research demonstrate that police officers must gain a deeper understanding of trauma and sensitive communication with survivors of sexual assault.