Prioritizing Residents\u27 Needs: On the Creation of a Residents as Teachers and Leaders Program

Introduction: Residents are responsible for the majority of medical student teaching and directly supervise, instruct, and evaluate students. Many organizations now recommend that residency training programs include venues specifically designed to develop resident teaching skills. [See PDF for abstract]

A video-based educational intervention for providers regarding colorectal cancer screening

Methods: Email sent to providers asking them to complete a 7 question survey regarding knowledge and self-reported comfort in screening for colorectal cancer using a shared decision-making approach.https://jdc.jefferson.edu/patientsafetyposters/1045/thumbnail.jp

Practice Management Guidelines for the Diagnosis and Management of Injury in the Pregnant Patient: The EAST Practice Management Guidelines Work Group

Trauma during pregnancy has presented very unique challenges over the centuries. From the first report of Ambrose Pare of a gunshot wound to the uterus in the 1600s to the present, there have existed controversies and inconsistencies in diagnosis, management, prognostics, and outcome. Anxiety is heightened by the addition of another, smaller patient. Trauma affects 7% of all pregnancies and requires admission in 4 of 1000 pregnancies. The incidence increases with advancing gestational age. Just over half of trauma during pregnancy occurs in the third trimester. Motor vehicle crashes comprise 50% of these traumas, and falls and assaults account for 22% each. These data were considered to be underestimates because many injured pregnant patients are not seen at trauma centers. Trauma during pregnancy is the leading cause of nonobstetric death and has an overall 6% to 7% maternal mortality. Fetal mortality has been quoted as high as 61% in major trauma and 80% if maternal shock is present. The anatomy and physiology of pregnancy make diagnosis and treatment difficult

Demographic and Psychosocial Factors Associated with Suicide Mortality Among Childbearing-Aged Individuals: A Case-Control Study

Objective: Examine pregnancy-related, demographic, psychosocial and healthcare utilization factors associated with suicide mortality among childbearing-aged women. Methods: Data from nine health care systems in the Mental Health Research Network were included. A case-control study design was used in which 290 childbearing-age women who died by suicide (cases) from 2000-2015 were matched with 2,900 childbearing-age women from the same healthcare system and enrolled during the same time period who did not die by suicide. Conditional logistic regression was used to analyze associations between patient characteristics and suicide. Results: Women who died by suicide were more likely to have mental health or substance use disorders (aOR = 2.36, 95%CI: 1.46, 3.82) and to have visited the emergency department in the year prior to index date (aOR = 3.35, 95%CI: 2.39, 4.68). Pregnancy (aOR = 0.17, 95% CI: 0.04, 0.78) and delivery of a liveborn baby (aOR = 0.39, 95% CI: 0.16, 0.92) within a year before index date were associated with lower risk of suicide mortality. Women who experienced pregnancy loss were more likely to die by suicide (aOR = 1.41, 95% CI: 0.49, 4.06), but this was not statistically significant potentially due to small sample size (n = 6 cases; n = 21 control). Conclusions: Childbearing-aged women with mental health and/or substance use disorders, prior emergency department encounters may benefit from routine screening and monitoring for suicide risk. Future research should further examine the relationship between pregnancy loss and suicide mortality

Safeguarding Youth Mental Health

Session Objectives Background: Introductions Problem: State of Behavioral Health Methods & Results: Boston\u27s Opportunities Future Direction

Increasing Prevalence of Gestational Diabetes and Pregnancy-Related Hypertension in Los Angeles County, California, 1991–2003

IntroductionGestational diabetes and pregnancy-related hypertension can lead to adverse health effects in mothers and infants. We assessed recent trends in the rates of these conditions in Los Angeles County, California.MethodsHospital discharge data were used to identify all women aged 15–54 years who resided in the county, had a singleton delivery from 1991 through 2003, and had gestational diabetes or pregnancy-related hypertension listed as a discharge diagnosis at the time of delivery. The prevalence of each condition was calculated by calendar year, race/ethnicity, and age group. Temporal trends in the rates were assessed by using negative binomial regression models, controlling for race/ethnicity and age. Separate models were run for each racial/ethnic and age group.ResultsThe age-adjusted prevalence of gestational diabetes increased more than threefold (from 14.5 cases per 1000 women in 1991 to 47.9 cases per 1000 in 2003). The age-adjusted prevalence of pregnancy-related hypertension also increased (from 40.5 cases per 1000 in 1991 to 54.4 cases per 1000 in 2003). In the multivariable regression analysis, the annual rate increase for gestational diabetes was 8.3% overall and was highest among Hispanics (9.9%). The annual rate increase for pregnancy-related hypertension was 2.8% overall and was highest among blacks (4.8%).ConclusionThe rates of gestational diabetes and pregnancy-related hypertension are increasing in Los Angeles County. Further research is needed to determine the causes of the observed increases and the growing racial/ethnic disparities in those rates

Sensitivity of the Saline Load Test for Traumatic Arthrotomy of the Ankle

Category: Ankle Introduction/Purpose: The saline load test is routinely used to evaluate for traumatic arthrotomy in orthopaedics. The purpose of this study was to determine the volume of saline required to detect traumatic arthrotomy of the ankle. Methods: 42 patients undergoing elective ankle arthroscopy were prospectively enrolled. For each patient, a standard 4 mm anteromedial portal was established. Next, an 18-guage needle was inserted at the site of the anterolateral portal. Sterile saline was slowly injected through the needle until saline extravasated from the anteromedial portal. Saline volumes at the time of extravasation were recorded and analyzed. Results: The saline volume required to achieve extravasation ranged from 0.2mL-60.0 mL (Figure 1A). The median saline volume required to achieve extravasation (and interquartile range) was 9.7 mL (3.8-29.6 mL); however, five of 42 patients required volumes between 50.0 mL and 60.0 mL. A total of 50.0 mL was required to achieve 90% sensitivity, 55.0 mL to achieve 95% sensitivity, and 60.0 mL to achieve 99% sensitivity (Figure 1B). Conclusion: The previously recommended 30 mL of saline required to reliably detect traumatic arthrotomy of the ankle may be too small a volume. The present study suggests that clinicians should attempt to inject 60 mL in order to effectively rule out a traumatic arthrotomy injury

Total Ankle Arthroplasty Is Safer than Total Hip and Knee Arthroplasty

Category: Ankle Arthritis Introduction/Purpose: Total hip and knee arthroplasty (THA and TKA) are performed far more commonly than total ankle arthroplasty (TAA), so patients and the orthopaedic community have a better understanding of the complication profile for THA and TKA than for TAA. The present study compares adverse event rates, the rate of blood transfusion, operative times, length of stay, and the rate of hospital readmission between TAA, THA, and TKA procedures. Methods: Patients were identified who underwent TAA, THA, or TKA during 2006-2016 as part of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). Multivariate regression was used to compare TAA to THA and TKA in terms of adverse event rates, the rate of blood transfusion, operative times, length of stay, and the rate of hospital readmission. All analyses were fully adjusted for differences in baseline demographic, comorbidity, and procedural characteristics, including type of anesthesia. The level of significance was set at p<0.05. Results: A total of 138,325 patients were identified as having undergone THA, 223,587 TKA, and 839 TAA. The total complication rate was lower for TAA (2.98%) compared to THA (4.92%, p=0.011) and TKA (4.56%, p=0.049; Table 1). Similarly, the rate of blood transfusion was lower for TAA (0.48%) compared to THA (9.66%, p<0.001) and TKA (6.44%, p<0.001). Interestingly, operative time was approximately an hour longer for TAA (157.7 minutes) compared to THA (93.6 minutes, p<0.001) and TKA (93.7 minutes, p<0.001). Length of stay was approximately one day shorter for TAA (1.9 days) compared to THA (2.9 days, p<0.001) and TKA (3.0 days, p<0.001). Finally, the rate of readmission was lower for TAA (1.5%) compared to THA (3.7%, p=0.002) and TKA (3.4%, p=0.005). Conclusion: TAA is a relatively rare procedure to which patients may not have had much exposure. Patients considering TAA are more likely to have had exposure to more common procedures such as THA and TKA (through family, friends, their own procedures, etc.). Patients can be counseled that relative to THA and TKA, TAA is a safer procedure in the perioperative time frame, with significantly lower rates of adverse events, blood transfusion, additional surgery, and hospital readmission. Their procedures can be expected to take longer, but their hospital stays can be expected to be shorter

Quality of Modern Total Ankle Arthroplasty Research

Category: Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) is gaining popularity as an alternative to ankle arthrodesis in the setting of end-stage ankle arthritis. However, compared to hip and knee arthroplasty, there is a relative dearth of evidence to support its use. This study assesses the quality of literature surrounding modern TAA designs. Methods: A search of all peer-reviewed, English-language journals was conducted to identify publications involving TAA. The initial search identified 444 articles published during 2006-2016. Of these, 182 were excluded because they were not clinical outcomes studies, 46 because the TAA implant was no longer available, and 15 because the primary outcome of the study was not related to TAA, leaving 201 articles for analysis. Results: No Level I studies were identified. Seventeen (8%) studies were Level II, 48 (24%) Level III, 128 (64%) Level IV, and 8 (4%) Level V. One hundred forty-three studies (71%) were retrospective in nature. Stratification by study design revealed 128 (64%) case series, 33 (16%) experimental cohort studies, 19 (10%) case-control studies, 13 (6%) observational cohort studies, and 8 (4%) case reports. The number of studies published each year steadily increased from 2006 to 2016. A total of 51% of TAA research was published in only two journals: Foot and Ankle International and the Journal of Bone and Joint Surgery. Publications from the United States accounted for 36% of total publications. The most published implant was the Scandinavian Total Ankle Replacement (Figure 1). Conclusion: While the number of TAA studies published each year has steadily increased since 2006, the quality of this research as measured by level of evidence remains suboptimal. This analysis highlights the need for continued improvement in methodology and development of robust prospective registries to advance our knowledge of TAA as a treatment for end-stage ankle arthritis

Validated Risk Stratification System for Prediction of Adverse Events Following Open Reduction and Internal Fixation of the Ankle

Category: Ankle Introduction/Purpose: As orthopaedic surgery moves towards bundled payments, there is growing interest in identifying patients at high risk for postoperative adverse events. The purpose of this study is to develop and validate a risk stratification system for the occurrence of adverse events following open reduction and internal fixation (ORIF) of the ankle. Methods: Patients undergoing ORIF of closed ankle fractures as part of the National Surgical Quality Improvement Program (NSQIP) were identified. For patients undergoing surgery during 2006-2014, multivariate Cox proportional hazards modeling was used to identify factors that were independently associated with the occurrence of adverse events (including events such as surgical site infection, myocardial infarction, and pulmonary embolism). Based on these results, a nomogram was used to generate a point-scoring system for risk stratification. To evaluate the validity of the point-scoring system, the system was applied to patients undergoing ankle ORIF during 2015-2016. Results: Of the 6,140 patients undergoing surgery during 2006-2014, 5.8% developed an adverse event. Based on the Cox proportional hazards regression, patients were assigned points for each of the following statistically significant risk factors: anemia (+2 points), insulin-dependent diabetes (+2 points), age=65 (+1 point), dependent functional status (+1 point), chronic obstructive pulmonary disease (COPD; +1 point), and hypertension (+1 point; Figure 1A). 4,702 patients were identified in the 2015-2016 validation cohort. Among these patients, the risk-stratification system was found to strongly predict the risk for adverse events (p<0.001, Figure 1B). Conclusion: The occurrence of adverse events following ankle ORIF is associated with anemia, insulin-dependent diabetes, age=65, dependent functional status, COPD, and hypertension. We present and validate a simple point-scoring risk stratification system to predict the risk of adverse events. Future systems of bundled payments for ankle ORIF should exclude high-risk patients from the bundling systems, or make appropriate adjustments in reimbursement based on risk