Brief Note: Smooth-billed Ani (Crotophaga ani L.), a New Species of Bird for Ohio

Author Institution: Department of Biology, John Carroll University ; Department of Vertebrate Zoology, The Cleveland Museum of Natural HistoryA smooth-billed ani (Crotophaga ani L.) is reported from Ohio for the first time. The specimen (CMNH 68471) also represents the first inland state record for the United States. Confirmation of specific identity was obtained because of the significance of the record and some equivocal characteristics of the specimen. Care in field identification of extralimital anis is suggested

Routine fixation of humeral shaft fractures is cost-effective:cost-utility analysis of 215 patients at a mean of five years following nonoperative management

Aims: The primary aim was to estimate the cost-effectiveness of routine operative fixation for all patients with humeral shaft fractures. The secondary aim was to estimate the health economic implications of using a Radiographic Union Score for HUmeral fractures (RUSHU) of < 8 to facilitate selective fixation for patients at risk of nonunion. Methods: From 2008 to 2017, 215 patients (mean age 57 yrs (17 to 18), 61% female (n = 130/215)) with a nonoperatively managed humeral diaphyseal fracture were retrospectively identified. Union was achieved in 77% (n = 165/215) after initial nonoperative management, with 23% (n = 50/215) uniting after surgery for nonunion. The EuroQol five-dimension three-level health index (EQ-5D-3L) was obtained via postal survey. Multiple regression was used to determine the independent influence of patient, injury, and management factors upon the EQ-5D-3L. An incremental cost-effectiveness ratio (ICER) of < £20,000 per quality-adjusted life-year (QALY) gained was considered cost-effective. Results: At a mean of 5.4 yrs (1.2 to 11.0), the mean EQ-5D-3L was 0.736 (95% confidence interval (CI) 0.697 to 0.775). Adjusted analysis demonstrated the EQ-5D-3L was inferior among patients who united after nonunion surgery (β = 0.103; p = 0.032). Offering routine fixation to all patients to reduce the rate of nonunion would be associated with increased treatment costs of £1,542/patient, but would confer a potential EQ-5D-3L benefit of 0.120/patient over the study period. The ICER of routine fixation was £12,850/QALY gained. Selective fixation based on a RUSHU < 8 at six weeks post-injury would be associated with reduced treatment costs (£415/patient), and would confer a potential EQ-5D-3L benefit of 0.335 per ‘at-risk patient’. Conclusion: Routine fixation for patients with humeral shaft fractures to reduce the rate of nonunion observed after nonoperative management appears to be a cost-effective intervention at five years post-injury. Selective fixation for patients at risk of nonunion based on their RUSHU may confer even greater cost-effectiveness, given the potential savings and improvement in health-related quality of life. Cite this article: Bone Jt Open 2022;3(7):566–572

Management of Lisfranc Injuries:A Critical Analysis Review

»: There is a spectrum of midtarsal injuries, ranging from mild midfoot sprains to complex Lisfranc fracture-dislocations.»: Use of appropriate imaging can reduce patient morbidity, by reducing the number of missed diagnoses and, conversely, avoiding overtreatment. Weight-bearing radiographs are of great value when investigating the so-called subtle Lisfranc injury.»: Regardless of the operative strategy, anatomical reduction and stable fixation is a prerequisite for a satisfactory outcome in the management of displaced injuries.»: Fixation device removal is less frequently reported after primary arthrodesis compared with open reduction and internal fixation based on 6 published meta-analyses. However, the indications for further surgery are often unclear, and the evidence of the included studies is of typically low quality. Further high-quality prospective randomized trials with robust cost-effectiveness analyses are required in this area.»: We have proposed an investigation and treatment algorithm based on the current literature and clinical experience of our trauma center.</p

A Resident Retreat with Emergency Medicine Specific Mindfulness Training Significantly Reduces Burnout and Perceived Stress

Introduction: We hypothesize that a resident retreat with mindfulness training tailored for Emergency Medicine (EM) physicians can significantly reduce levels of burnout and perceived stress in EM residents. Methods: We conducted an intervention study of 60 EM residents undergoing an annual resident retreat with a 2.5-hour mindfulness training. The retreat was a department-funded 2-day off-site experience with a wellness theme. The training was developed and delivered by an EM physician (JO\u27S) who is a Mindfulness-Based Stress Reduction (MBSR) teacher trainee, and a certified MBSR teacher (MD). The training focused on techniques that can be used on shift, such as mindful breathing, handwashing, eating/drinking, walking, and anchoring before resuscitations. The cohort contained an equal distribution of 1st, 2nd and 3rd year residents who received a financial incentive. The subjects completed the Maslach Burnout Inventory, Perceived Stress Scale and Mindful Attention and Awareness Scale at three time points: Time 1 - one month prior, Time 2 – one week post, Time 3 – one month post. Results: The subjects were 60 EM residents (54% Male, 46% Female) with an average age of 29. Completion rates at the three time points were 70% (n = 42), 60% (n = 36) and 50% (n = 30) respectively. We found that Perceived Stress (ω2 = 0.15, p \u3c 0.01) and Emotional Exhaustion (ω2 = 0.21, p \u3c 0.01) decreased significantly over time in a linear progression across the three sampling periods. Though mindfulness as a trait did not change significantly during the study period, in the month after the retreat, 64% of resident respondents at Time 3 (n = 32) reported using the mindfulness techniques learned from the training at least 2 or 3 times a week on shift and 52% (n = 31) reported using them at least 2 or 3 times a week at home. Conclusions: An EM resident retreat that included an EM specific mindfulness training significantly reduced perceived stress and emotional exhaustion. The learned mindfulness skills were readily adopted for use on shift. Further studies should investigate effectiveness of mindfulness training outside of the retreat format. Other wellness / academic activities that occur within the socially supportive milieu of a retreat could lead to the same significant reduction in burnout and perceived stress seen in the current study

Surgical Versus Nonsurgical Management of Humeral Shaft Fractures:a systematic review and meta-analysis of randomised trials

Introduction: The aim was to compare operative and non-operative management for adults with humeral shaft fractures, in terms of patient-reported upper limb function, health-related quality of life (HRQoL), radiographic outcomes and complications.Methods: MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), PubMed, CENTRAL (Cochrane Central Register of Controlled Trials), ClinicalTrials.gov, ISRCTN (International Clinical Trials Registry) and OpenGrey (Repository for Grey Literature in Europe) were searched in September 2021. All published prospective randomised trials comparing operative and non-operative management of humeral shaft fractures in adults were included. Of 715 studies identified, five were included in the systematic review and four in the meta-analysis. Data were extracted by two independent reviewers according to the PRISMA statement. Methodological quality was assessed using the revised Cochrane risk-of-bias tool for randomised trials. Pooled data were analysed using a random-effects model.Results: The meta-analysis comprised 292 patients (mean age 41yrs [18-83], 67% male). Surgery was associated with superior DASH and Constant-Murley scores at six months (mean DASH difference 7.6, p=0.01; mean Constant-Murley difference 8.0, p=0.003) but there was no difference at one year (DASH, p=0.30; Constant-Murley, p=0.33). No differences in HRQoL or pain scores were found. Surgery was associated with a lower risk of nonunion (0.7% versus 15.7%; odds ratio [OR] 0.13, p=0.004). The number-needed-to-treat (NNT) with surgery to avoid one nonunion was 7. Surgery was associated with a higher risk of transient radial nerve palsy (17.4% versus 0.7%; OR 8.23, p=0.01) but not infection (OR 3.57, p=0.13). Surgery was also associated with a lower risk of re-intervention (1.4% versus 19.3%; OR 0.14, p=0.04).Conclusions: Surgery may confer an early functional advantage to adults with humeral shaft fractures, but this is not sustained beyond six months. The lower risk of nonunion should be balanced against the higher risk of transient radial nerve palsy.<br/

Operative vs Nonoperative Management of Unstable Medial Malleolus Fractures:A Randomized Clinical Trial

IMPORTANCE: Unstable ankle fractures are routinely managed operatively. However, because of soft tissue and implant-related complications, recent literature has reported on the nonoperative management of well-reduced medial malleolus fractures after fibular stabilization, but with limited evidence supporting the routine application.OBJECTIVE: To assess the superiority of internal fixation of well-reduced (displacement ≤2 mm) medial malleolus fractures compared with nonfixation after fibular stabilization.DESIGN, SETTING, AND PARTICIPANTS: This superiority, pragmatic, parallel, prospective randomized clinical trial was conducted from October 1, 2017, to August 31, 2021. A total of 154 adult participants (≥16 years) with a closed, unstable bimalleolar or trimalleolar ankle fracture requiring surgery at an academic major trauma center in the UK were assessed. Exclusion criteria included injuries with no medial-sided fracture, open fractures, neurovascular injury, and the inability to comply with follow-up. Data analysis was performed in July 2022 and confirmed in September 2023.INTERVENTIONS: Once the lateral (and where appropriate, posterior) malleolus had been fixed and satisfactory intraoperative reduction of the medial malleolus fracture was confirmed by the operating surgeon, participants were randomly allocated to fixation (n = 78) or nonfixation (n = 76) of the medial malleolus.MAIN OUTCOME AND MEASURE: Olerud-Molander Ankle Score (OMAS) 1 year after randomization (range, 0-100 points, with 0 indicating worst possible outcome and 100 indicating best possible outcome).RESULTS: Among 154 randomized participants (mean [SD] age, 56.5 [16.7] years; 119 [77%] female), 144 (94%) completed the trial. At 1 year, the median OMAS was 80.0 (IQR, 60.0-90.0) in the fixation group compared with 72.5 (IQR, 55.0-90.0) in the nonfixation group (P = .17). Complication rates were comparable. Significantly more patients in the nonfixation group developed a radiographic nonunion (20% vs 0%; P &lt; .001), with 8 of 13 clinically asymptomatic; 1 patient required surgical reintervention for this. Fracture type and reduction quality appeared to influence fracture union and patient outcome.CONCLUSIONS AND RELEVANCE: In this randomized clinical trial comparing internal fixation of well-reduced medial malleolus fractures with nonfixation, after fibular stabilization, fixation was not superior according to the primary outcome. However, 1 in 5 patients developed a radiographic nonunion after nonfixation, and although the reintervention rate to manage this was low, the future implications are unknown. These results support selective nonfixation of anatomically reduced medial malleolar fractures after fibular stabilization.TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03362229.</p

Outcome following mini-open lower limb fasciotomy for chronic exertional compartment syndrome

PURPOSE: The aim of this study was to report outcomes following mini-open lower limb fasciotomy (MLLF) in active adults with chronic exertional compartment syndrome (CECS). METHODS: From 2013–2018, 38 consecutive patients (mean age 31 years [16–60], 71% [n = 27/38] male) underwent MLLF. There were 21 unilateral procedures, 10 simultaneous bilateral and 7 staged bilateral. There were 22 anterior fasciotomies, five posterior and 11 four-compartment. Early complications were determined from medical records of 37/38 patients (97%) at a mean of four months (1–19). Patient-reported outcomes (including EuroQol scores [EQ-5D/EQ-VAS], return to sport and satisfaction) were obtained via postal survey from 27/38 respondents (71%) at a mean of 3.7 years (0.3–6.4). RESULTS: Complications occurred in 16% (n = 6/37): superficial infection (11%, n = 4/37), deep infection (3%, n = 1/37) and wound dehiscence (3%, n = 1/37). Eight per cent (n = 3/37) required revision fasciotomy for recurrent leg pain. At longer-term follow-up, 30% (n = 8/27) were asymptomatic and another 56% (n = 15/27) reported improved symptoms. The mean pain score improved from 6.1 to 2.5 during normal activity and 9.1 to 4.7 during sport (both p < 0.001). The mean EQ-5D was 0.781 (0.130–1) and EQ-VAS 77 (33–95). Of 25 patients playing sport preoperatively, 64% (n = 16/25) returned, 75% (n = 12/16) reporting improved exercise tolerance. Seventy-four per cent (n = 20/27) were satisfied and 81% (n = 22/27) would recommend the procedure. CONCLUSION: MLLF is safe and effective for active adults with CECS. The revision rate is low, and although recurrent symptoms are common most achieve symptomatic improvement, with reduced activity-related leg pain and good health-related quality of life. The majority return to sport and are satisfied with their outcome