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To determine the effects of blood flow restriction (BFR) on the mean firing rate (MFR) and motor unit action potential amplitude (MUAPAMP) VS. recruitment threshold (RT) relationships during fatiguing isometric elbow flexions. Ten men (24.5 ± 4.0 years) performed isometric trapezoidal contractions at 50% maximum voluntary contraction to task failure with or without BFR, on 2 separate days. For BFR, a cuff was inflated to 60% of the pressure required for full brachial artery occlusion at rest. During both visits, surface electromyography was recorded from the biceps brachii of the dominant limb and the signal was decomposed. A paired-samples t test was used to determine the number of repetitions completed between BFR and CON. ANOVAS (repetition [first, last] × condition [BFR, CON]) were used to determine differences in MFR vs. RT and MUAPAMP VS. RT relationships. Subjects completed more repetitions during CON (12 ± 4) than BFR (9 ± 2; p = 0.012). There was no significant interaction (p > 0.05) between the slopes and y-intercepts during the repetition X condition interaction for MUAPAMP VS. MFR. However, there was a main effect of repetition for the slopes of the MUAPAMP VS. RT (p = 0.041) but not the y-intercept (p = 0.964). Post hoc analysis (collapsed across condition) indicated that the slopes of the MUAPAMP VS. RT during the first repetition was less than the last repetition (first: 0.022 ± 0.003 mv/%MVC; last: 0.028 ± 0.004 mv/%MVC; p = 0.041). Blood flow restriction resulted in the same amount of higher threshold MU recruitment in approximately 75% of the repetitions. Furthermore, there was no change in MFR for either condition, even when taken to task failure. Thus, BFR training may create similar MU responses with less total work completed than training without BFR. [ABSTRACT FROM AUTHOR]

In this article, we describe our experience developing and implementing a multipronged approach to improve performance across a strategic subset of quality measures within primary care. Detailed techniques include data visualization and analytics, process reengineering, team engagement, visual project management, continuous improvement methods and training, and incentives and recognition. We achieved positive change across 12 high priority measures which we deemed the "High Value Framework (HVF)" by fostering a collaborative, nonpunitive, problem-solving culture. We focused on measures that had the greatest potential for impact from a clinical, reimbursement, and reputational perspective. More importantly, we sustained gains despite the challenges posed by the COVID-19 pandemic, thereby demonstrating programmatic resilience and high process reliability. This systematic approach serves as a practical blueprint for other healthcare entities seeking to navigate the complexities of quality improvement in a dynamic environment. The model provides a strategic framework for prioritizing and standardizing quality measures, effectively engaging stakeholders, and managing organizational change. Our model emerged from a need to address real-world operational challenges, rather than as an academic or theoretical exercise, and was developed independently of existing literature on measure prioritization and standardization at the time of its inception. [ABSTRACT FROM AUTHOR]

BACKGROUND: Irrigated radiofrequency ablation with half-normal saline can potentially increase lesion size but may increase the risk of steam pops with the risk of emboli or perforation. We hypothesized that pops would be preceded by intracardiac echocardiography (ICE) findings as well as a large impedance fall. METHODS: In 100 consecutive patients undergoing endocardial ventricular arrhythmia radiofrequency ablation with half-normal saline, we attempted to observe the ablation site with ICE. Radiofrequency ablation power was titrated to a 15 to 20 Ohm impedance fall and could be adjusted for tissue whitening and increasing bubble formation on ICE. Steam pops were defined as audible or a sudden explosion of microbubbles on ICE. RESULTS: Of 2190 ablation applications in 100 patients (82% cardiomyopathy, 50% sustained ventricular tachycardia), pops occurred during 43 (2.0%) applications. Sites with pops had greater impedance decreases of 18 [14, 21]% versus 13 [10, 17]% (P<0.001). ICE visualized 1308 (59.7%) radiofrequency sites, and fewer pops occurred when ICE visualized the radiofrequency ablation site (1.4%) compared with without ICE visualization (2.8%; P=0.016). Of the 18 ICE-visible pops, 7 (39%) were silent but recognized as an explosion of bubbles on ICE. With ICE, 89% of pops were preceded by either tissue whitening or a sudden increase in bubbles. In a multivariable model, tissue whitening and a sudden increase in bubbles were associated with steam pops (odds ratio, 7.186; P=0.004, and odds ratio, 29.93; P<0.001, respectively), independent of impedance fall and power. There were no pericardial effusions or embolic events with steam pops. CONCLUSIONS: Steam pops occurred in 2% of half-normal saline radiofrequency applications titrated to an impedance fall and are likely under-recognized without ICE. On ICE, steam pops are usually preceded by tissue whitening or a sudden increase in bubble formation, which can potentially be used to adjust radiofrequency application to help reduce pops. [ABSTRACT FROM AUTHOR]

BACKGROUND: The American Board of Surgery has endorsed competency-based education as vital to the assessment of surgical training. From 2018 to 2020, a national pilot study was conducted at 28 general surgery programs to evaluate feasibility of implementing entrustable professional activities (EPAs) for 5 common general surgical conditions. ACGME core competency Milestones were also rated for each resident by program clinical competency committees. This study aimed to evaluate the validity of general surgery EPAs compared with Milestones. STUDY DESIGN: Prospectively collected, de-identified EPA Pilot Study data were analyzed. EPAs studied were EPA-1 (gallbladder), EPA-2 (inguinal hernia), EPA-3 (right lower quadrant pain), EPA-4 (trauma), and EPA-5 (consult). Variables abstracted included levels of EPA entrustment (1 to 5) and corresponding ACGME Milestone subcompetency ratings (1 to 5) for the same study cycle. Spearman's correlations were used to evaluate the relationship between summative EPA scores and corresponding Milestone ratings. RESULTS: A total of 493 unique residents received a summative entrustment decision. EPA summative entrustment scores had moderate-to-strong positive correlation with mapped Milestone subcompetencies, with median rho value of 0.703. Among operation-focused EPAs, median rho values were similar between EPA-1 (0.688) and EPA-2 (0.661), but higher for EPA-3 (0.833). EPA-4 showed a strong positive correlation with diagnosis and communication competencies (0.724), whereas EPA-5, mapped to the most Milestone subcompetencies, had the lowest median rho value (0.455). CONCLUSIONS: Moderate-to-strong positive correlation was noted between EPAs and patient care, medical knowledge, and communication Milestones. These findings support the validity of EPAs in general surgery and suggest that EPA assessments can be used to inform Milestone ratings by clinical competency committees. [ABSTRACT FROM AUTHOR]

Poor well-being and burnout among the nursing workforce were heightened by the COVID-19 pandemic. The purpose of this study was to deliver, spread, and sustain an evidence-based wellness program, Workforce Engagement for Compassionate Advocacy, Resilience, and Empowerment (WE CARE), for nurse leaders, staff registered nurses (RNs), and patient care technicians (PCTs) to ameliorate or prevent burnout, promote resilience, and improve the work environment. The program included Community Resiliency Model (CRM) training provided by a certified 6-member wellness team. A baseline and 6-month follow-up survey included measures of well-being, moral distress, burnout, resilience, perceived organizational support (POS), job satisfaction, intent to leave (ITL), and work environment. A total of 4900 inpatient RNs, PCTs, and leaders of a 1207-bed academic medical center in the southeastern United States were analyzed. From baseline (n = 1533) to 6-month follow-up (n = 1457), well-being, moral distress, burnout, job satisfaction, and work environment improved; however, resilience, POS, and ITL did not. Although we have seen some improvements in well-being and mental health indicators, it is still early in the intervention period to have reached a critical mass with the training and other interventions. The mental health and work environment issues among nurses are so complex, no one-size-fits-all intervention can resolve. [ABSTRACT FROM AUTHOR]

Objective: To determine the relationship between race/ethnicity and case volume among graduating surgical residents. Background: Racial/ethnic minority individuals face barriers to entry and advancement in surgery; however, no large-scale investigations of the operative experience of racial/ethnic minority residents have been performed. Methods: A multi-institutional retrospective analysis of the Accreditation Council for Graduate Medical Education case logs of categorical general surgery residents at 20 programs in the US Resident OPerative Experience Consortium database was performed. All residents graduating between 2010 and 2020 were included. The total, surgeon chief, surgeon junior, and teaching assistant case volumes were compared between racial/ethnic groups. Results: The cohort included 1343 residents. There were 211 (15.7%) Asian, 65 (4.8%) Black, 73 (5.4%) Hispanic, 71 (5.3%) "Other" (Native American or Multiple Race), and 923 (68.7%) White residents. On adjusted analysis, Black residents performed 76 fewer total cases (95% CI, -109 to -43, P< 0.001) and 69 fewer surgeon junior cases (-98 to -40, P<0.001) than White residents. Comparing adjusted total case volume by graduation year, both Black residents and White residents performed more cases over time; however, there was no difference in the rates of annual increase (10 versus 12 cases per year increase, respectively, P=0.769). Thus, differences in total case volume persisted over the study period. Conclusions: In this multi-institutional study, Black residents graduated with lower case volume than non-minority residents throughout the previous decade. Reduced operative learning opportunities may negatively impact professional advancement. Systemic interventions are needed to promote equitable operative experience and positive culture change. [ABSTRACT FROM AUTHOR]

The purpose of this review was to understand the research on carpal tunnel syndrome in athletes who compete in wheelchair sport. Eight articles were identified using the search strategy. The most common sport evaluated was wheelchair basketball (N = 4). Most athletes were male and were diagnosed with a spinal cord injury. Different clinical and electrodiagnostic criteria have been used to diagnose carpal tunnel syndrome. Two studies incorporated ultrasound into the clinical evaluation of median nerve pathology. The duration of disability and wheelchair use were associated with increased risk of carpal tunnel syndrome in four studies. There was no association between training load and the prevalence of carpal tunnel syndrome. No study has explored the functional implications of carpal tunnel syndrome on sports participation and performance. No study has assessed the prevention and treatment of carpal tunnel syndrome in individuals who compete in wheelchair sport. This review provides an understanding of the important diagnostic tools, and demographic and training risk factors to consider when evaluating para-athletes for carpal tunnel syndrome and highlights areas for future research. [ABSTRACT FROM AUTHOR]

Background: Clinical guidelines recommend standing radiographs as the most appropriate imaging for detecting degenerative spondylolisthesis, although reliable evidence about the standing position is absent. To our knowledge, no studies have compared different radiographic views and pairings to detect the presence and magnitude of stable and dynamic spondylolisthesis. Questions/purposes: (1) What is the percentage of new patients presenting with back or leg pain with stable (3 mm or greater listhesis on standing radiographs) and dynamic (3 mm or greater listhesis difference on standing-supine radiographs) spondylolisthesis? (2) What is the difference in the magnitude of spondylolisthesis between standing and supine radiographs? (3) What is the difference in the magnitude of dynamic translation among flexion-extension, standing-supine, and flexion-supine radiographic pairs. Methods: This cross-sectional, diagnostic study was performed at an urban, academic institution between September 2010 and July 2016; 579 patients 40 years or older received a standard radiographic three-view series (standing AP, standing lateral, and supine lateral radiographs) at a new patient visit. Of those individuals, 89% (518 of 579) did not have any of the following: history of spinal surgery, evidence of vertebral fracture, scoliosis greater than 30°, or poor image quality. In the absence of a reliable diagnosis of dynamic spondylolisthesis using this three-view series, patients may have had flexion and extension radiographs, and approximately 6% (31 of 518) had flexion and extension radiographs. A total of 53% (272 of 518) of patients were female, and the patients had a mean age of 60 ± 11 years. Listhesis distance (in mm) was measured by two raters as displacement of the posterior surface of the superior vertebral body in relation to the posterior surface of the inferior vertebral body from L1 to S1; interrater and intrarater reliability, assessed with intraclass correlation coefficients, was 0.91 and 0.86 to 0.95, respectively. The percentage of patients with and the magnitude of stable spondylolisthesis was estimated on and compared between standing neutral and supine lateral radiographs. The ability of common pairs of radiographs (flexion-extension, standing-supine, and flexion-supine) to detect dynamic spondylolisthesis was assessed. No single radiographic view or pair was considered the gold standard because stable or dynamic listhesis on any radiographic view is often considered positive in clinical practice. Results: Among 518 patients, the percentage of patients with spondylolisthesis was 40% (95% CI 36% to 44%) on standing radiographs alone, and the percentage of patients with dynamic spondylolisthesis was 11% (95% CI 8% to 13%) on the standing-supine pair. Standing radiographs detected greater listhesis than supine radiographs did (6.5 ± 3.9 mm versus 4.9 ± 3.8 mm, difference 1.7 mm [95% CI 1.2 to 2.1 mm]; p < 0.001). Among 31 patients, no single radiographic pairing identified all patients with dynamic spondylolisthesis. The listhesis difference detected between flexion-extension was no different from the listhesis difference detected between standing-supine (1.8 ± 1.7 mm versus 2.0 ± 2.2 mm, difference 0.2 mm [95% CI -0.5 to 1.0 mm]; p = 0.53) and flexion-supine (1.8 ± 1.7 mm versus 2.5 ± 2.2 mm, difference 0.7 mm [95% CI 0.0 to 1.5]; p = 0.06). Conclusion: This study supports current clinical guidelines that lateral radiographs should be obtained with patients in the standing position, because all cases of stable spondylolisthesis of 3 mm or greater were detected on standing radiographs alone. Each radiographic pair did not detect different magnitudes of listhesis, and no single pair detected all cases of dynamic spondylolisthesis. Clinical concern for dynamic spondylolisthesis may justify standing neutral, supine lateral, standing flexion, and standing extension views. Future studies could identify and evaluate a set of radiographic views that provides the greatest capacity to diagnose stable and dynamic spondylolisthesis. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to evaluate the impact that domestic violence (DV) service organizations' (SO) agency-wide adoption of CARE had on improving DVSO trauma-informed care (TIC) practices, overall, and in relation to addressing brain injury and mental health. CARE is an advocacy intervention designed to raise DVSOs' capacity to CONNECT with survivors; ACKNOWLEDGE that head trauma, strangulation, and mental health challenges are common; RESPOND by accommodating needs in services and providing targeted referrals; and EVALUATE effectiveness of response to meet survivors' stated concerns. We hypothesized that TIC would significantly improve among DVSO staff with the agency's use of CARE. Setting/Participants/Design: Pre- (n = 53) and 1-year post-CARE (n = 60) implementation online surveys were completed by staff at 5 DVSOs in Ohio from 2017 to 2019. Main Measures: Trauma-Informed Practice Scales (TIPS) were used to assess agency support and overall staff impression of implementing TIC; scales were modified to assess the use of TIC-practices related to head trauma, strangulation, mental health, suicide, and substance use. Attitudes Regarding Trauma-Informed Care (ARTIC-45) subscales assessed DVSO staff's endorsement of personal and organizational support in implementing TIC practices. Response options on the Survivor Defined Practice Scale (SDPS) were modified to gain staff insight into DVSO's ability to facilitate survivor empowerment. Differences in endorsement of TIC practices between pre- and post-CARE implementation were evaluated using regression models. Results: DVSO agency environment (P < .01) and overall staff impression (P < .001) regarding implementing TIC practices, and in respect to head trauma (P < .01), strangulation (P < .01), mental health (P < .01), suicide (P = .04), and substance use (P < .01), significantly improved with the agency's use of CARE. CARE increased DVSO staff's belief in personal and organizational support to implement TIC (P < .01 and P = .02, respectively) and in their agency's ability to foster survivor empowerment (P < .01). Conclusion: CARE improved TIC practices of DVSOs, overall, and to address brain injury and mental health. [ABSTRACT FROM AUTHOR]

Objective: To examine differences in resident operative experience between male and female general surgery residents. Background: Despite increasing female representation in surgery, sex and gender disparities in residency experience continue to exist. The operative volume of male and female general surgery residents has not been compared on a multi-institutional level. Methods: Demographic characteristics and case logs were obtained for categorical general surgery graduates between 2010 and 2020 from the US Resident OPerative Experience Consortium database. Univariable, multivariable, and linear regression analyses were performed to compare differences in operative experience between male and female residents. Results: There were 1343 graduates from 20 Accreditation Council for Graduate Medical Education-accredited programs, and 476 (35%) were females. There were no differences in age, race/ethnicity, or proportion pursuing fellowship between groups. Female graduates were less likely to be high-volume residents (27% vs 36%, P < 0.01). On univariable analysis, female graduates performed fewer total cases than male graduates (1140 vs 1177, P < 0.01), largely due to a diminished surgeon junior experience (829 vs 863, P < 0.01). On adjusted multivariable analysis, female sex was negatively associated with being a high-volume resident (OR = 0.74, 95% CI: 0.56 to 0.98, P = 0.03). Over the 11-year study period, the annual total number of cases increased significantly for both groups, but female graduates (+16 cases/year) outpaced male graduates (+13 cases/year, P = 0.02). Conclusions: Female general surgery graduates performed significantly fewer cases than male graduates. Reassuringly, this gap in operative experience may be narrowing. Further interventions are warranted to promote equitable training opportunities that support and engage female residents. [ABSTRACT FROM AUTHOR]

Background: Depression affects up to 20% of primary care patients and negatively affects patients' mental and physical health. Local Problem: At a primary care clinic, a review of 291 patient records revealed that no patients were being screened for depression using a validated and reliable tool. Methods: The problem was addressed through the implementation of a depression screening and management protocol based on the U.S. Preventive Services Task Force guidelines. Processes used were recommended by the American College of Preventive Medicine and Institute for Clinical Systems Improvement. Interventions: This project implemented a protocol to screen, treat, and manage patients with depression at this primary care clinic. Analysis compared preimplementation and postimplementation metrics, including the number of patients screened for depression, newly diagnosed with depression, offered antidepressants, offered referral, and managed with follow-up. Results: Implementing a depression screening and management protocol in this clinic significantly increased depression screenings, the percent of patients newly diagnosed with depression, and the number of patients offered treatment. Conclusion: This quality improvement (QI) project improved screening, diagnosis, and management of patients with depression in this primary care clinic. A future QI project for this clinic should focus on measures to track improvements in patients with depression at this primary care clinic. [ABSTRACT FROM AUTHOR]

Issue: Health care management is faced with a basic conundrum about organizational behavior; why do professionals who are highly dedicated to their work choose to remain silent on critical issues that they recognize as being professionally and organizationally significant? Speaking-up interventions in health care achieve disappointing outcomes because of a professional and organizational culture that is not supportive. Critical Theoretical Analysis: Our understanding of the different types of employee silence is in its infancy, and more ethnographic and qualitative work is needed to reveal the complex nature of silence in health care. We use the sensemaking theory to elucidate how the difficulties to overcoming silence in health care are interwoven in health care culture. Insight/Advance: The relationship between withholding information and patient safety is complex, highlighting the need for differentiated conceptualizations of silence in health care. We present three Critical Challenge points to advance our understanding of silence and its roots by (1) challenging the predominance of psychological safety, (2) explaining how we operationalize sensemaking, and (3) transforming the role of clinical leaders as sensemakers who can recognize and reshape employee silence. These challenges also point to how employee silence can also result in a form of dysfunctional professionalism that supports maladaptive health care structures in practice. Practice Implications: Delineating the contextual factors that prompt employee silence and encourage speaking up among health care workers is crucial to addressing this issue in health care organizations. For clinical leaders, the challenge is to valorize behaviors that enhance adaptive and deep psychological safety among teams and within professions while modeling the sharing of information that leads to improvements in patient safety and quality of care. [ABSTRACT FROM AUTHOR]