Back on the Streets: Examining Emergency Department Return Rates for Unhoused Patients Discharged After Trauma

BACKGROUND

The unhoused population is at high risk for traumatic injuries and faces unique challenges in accessing follow-up care. However, there is scarce data regarding differences in Emergency Department (ED) return rates and reasons for return between unhoused and housed patients.

METHODS

We conducted a 3-year retrospective cohort study at a level-1 trauma center in a large metropolitan area. All patients who presented to the ED with traumatic injuries and were discharged without hospital admission were included in the study. The primary outcome was ED returns for trauma-related complications or new traumatic events <6 months after discharge. Patient characteristics and study outcomes were compared between housed and unhoused groups.

RESULTS

A total of 4184 patients were identified, of which 20.3% were unhoused. Compared to housed, unhoused patients were more likely to return to the ED (18.8% vs 13.9%, P < .001), more likely to return for trauma-related complications (4.6% vs 3.1%, P = .045), more likely to return with new trauma (7.1% vs 2.8%, P < .001), and less likely to return for scheduled wound checks (2.5% vs 4.3%, P = .012). Of the patients who returned with trauma-related complications, unhoused patients had a higher proportion of wound infection (20.5% vs 5.7%, P = .008). In the regression analysis, unhoused status was associated with increased odds of ED return with new trauma and decreased odds of return for scheduled wound checks.

CONCLUSIONS

This study observed significant disparities between unhoused and housed patients after trauma. Our results suggest that inadequate follow-up in unhoused patients may contribute to further ED return.

Inactive nurses' willingness to return to active nursing during the COVID-19 pandemic: A qualitative study

AIMS

To investigate factors that influence the willingness of inactive nurses to return to nursing in a crisis situation and to identify aspects that need to be considered with regard to a possible deployment.

DESIGN

A deductive and inductive qualitative content analysis of semi-structured focus group interviews.

METHODS

Semi-structured focus group interviews with inactive or marginally employed nurses, nurses who have been inactive for some time and nursing home managers in October and November 2021. The participating inactive nurses had declared their willingness for a deployment during the COVID-19 pandemic or not. Data were analysed using qualitative content analysis.

RESULTS

Communication was seen as essential by the participants for an informed decision for or against a temporary return to nursing and to potential or actual deployments. To make them feel safe, inactive nurses need to know what to expect and what is expected of them, for example, regarding required training and responsibilities. Considering their current employment status, some flexibility in terms of deployment conditions is needed. A remaining attachment to care can trigger a sense of duty. Knowledge of (regular) working conditions in nursing can lead to both a desire to support former colleagues and a refusal to be exposed to these conditions again.

CONCLUSION

Past working experiences and the current employment situation play a major role in the willingness of inactive nurses to return to nursing in a crisis situation. Unbureaucratic arrangements must be provided for those who are willing to return.

SUMMARY STATEMENT

What already is known - In crisis situations, not every inactive nurse is willing or able to return to nursing and therefore, the 'silent reserve' may not be as large as suspected. What this paper adds - Inactive nurses need to know what to expect and what is expected of them for their decision regarding a return to active patient care during a crisis situation. Implications for practice/policy - Inactive nurses need to be informed and should be offered free training and refresher courses to ensure patient safety.

IMPACT

This research shows that the group of inactive nurses are not a silent workforce which can be activated anytime. Those who are able and willing to return to direct patient care in crisis situations need the best possible support - during and between crises.

REPORTING METHOD

This study adhered to COREQ guidelines.

NO PATIENT OR PUBLIC CONTRIBUTION

The involvement of patients or members of the public did not apply for the study, as the aim was to gain insight into the motivations and attitudes of the group of inactive nurses.

Inpatient Rehabilitation of Hematopoietic Stem Cell Transplant Patients: Managing Challenging Impairments and Medical Fragility

ABSTRACT

Hematopoietic stem cell transplants play an important role in the treatment of cancer, particularly hematologic malignancies. These patients can encounter functional impairments unique to hematopoietic stem cell transplant, including deconditioning, cancer-related fatigue, steroid myopathy, graft versus host disease, and capillary leak syndrome. Medical fragility and increased risk of infection may make rehabilitation challenging on the acute care and postacute care settings. Patients admitted to acute inpatient rehabilitation experience a high rate of transfer to the primary acute service and high rate of mortality after transfer back. Physical medicine and rehabilitation physicians can use a number of strategies to mitigate these patients' risk of medical complications including evidence-based predictive models to assist with postacute rehabilitation triage, physiatry-led consult-based rehabilitation, and oncology hospitalist comanagement on inpatient rehabilitation.

COVID-19 and stock market performance: Evidence from the RCEP countries☆

As the world's largest trading bloc, the agreement of RCEP, which was formalized in September 2020, is believed to play a non-neglectable role in the post-pandemic recovery. Real economies and the capital markets of the participating countries will have greater interactions due to tariff reduction and negative lists. By looking into the shocks in early 2020 that affect the stock markets of RCEP participating countries, we measure the stock market reaction to common risks just before the RCEP agreement was formalized. Following return-based, volume-based and liquidity-based event-study approaches, we use daily data from 11 Asia-Pacific countries to examine the stock market reactions. We find that RCEP economies for which the agreement took effect on January 1st, 2022 showed better risk resistance in response to COVID-19 shocks. In the long run, trading benefits brought by the RCEP agreement are expected to form and strengthen a system of circular flow of international trading activities among the participating countries, which will in turn increase the risk resistance ability of their stock markets.

Influence of the COVID-19 pandemic; Comparative retrospective study and short-term results

AIMS

Our objective is to compare the functional results in patients that underwent surgery for recurrent anterior shoulder instability (RAGHI) during the COVID-19 pandemic with remotely-based rehabilitation, to those who had surgery before the pandemic and had in-person rehabilitation therapy.

METHODS

A retrospective case series of 68 patients were included and divided into two groups: In person-group and Home-based group. Western Ontario Shoulder Instability Index (WOSI) and Subjective Shoulder Value (SSV) scores were used to evaluate objective and subjective clinical parameters. Time and level of return to sports was studied by the Subjective Patient Outcome for Return to Sports (SPORTS) score.

RESULTS

The mean SSV score was 82% (40-100) on the In-Person group compared with 87% (65-100) for the Home-Based group. Results for WOSI score were similar, with an average of 210.42 (90%) for In-Person and 261.45 (88%) for the Home-Based group (p 0.12). Return to sports was carried out in an average of 6.6 (4-16) months for In-Person group, compared to 6.5 (5-8) months for Home-Based.

CONCLUSION

Follow-up and rehabilitation methods for patients who underwent surgery for RAGHI, during COVID-19 lockdown, were not significantly (p 0.12) affected on functional and athletic return in comparison to traditional methods according to WOSI scale.

LEVEL OF EVIDENCE

IV Retrospective series of cases.

Return to sport or work following surgical management of scapholunate ligament injury: a systematic review

INTRODUCTION

This systematic review aims to compare the rate and time to return to sport or work following surgical interventions for isolated scapholunate ligament (SLL) injury.

SOURCES OF DATA

A PRISMA-compliant systematic search of Medline, EMBASE, Cochrane, AMED, CINAHL Plus and SPORTDiscus was performed using keywords 'scapholunate', 'scapholunate ligament', 'scaphoid lunate', 'sport', 'sport injury', 'athlete', 'athletic performance', 'elite', 'return to sport', 'training', 'work', 'activity', 'return to activity'. Adult patients with isolated SLL injury, without osteoarthritis, were included.

AREAS OF AGREEMENT

Fourteen papers, including six different surgical interventions, met the criteria for the final analysis. All surgical techniques demonstrated acceptable rates of return to work or sport (>80%).

AREAS OF CONTROVERSY

The optimal surgical intervention for isolated SLL injury remains undetermined due to heterogeneity and limited sample sizes of published studies.

GROWING POINTS

This systematic review has provided clarification on the available literature on treatment modalities for isolated SLL injuries in the absence of osteoarthritis.

AREAS TIMELY FOR DEVELOPING RESEARCH

Prospective, randomized, primary studies are needed to establish optimal treatment for acute isolated SLL injuries.

To come back or not to come back during the coronavirus crisis-A cross-sectional online survey of inactive nurses

Aims

To examine whether inactive nurses are willing to return to nursing during the COVID‐19 pandemic, the reasons for or against their decision and further, possibly relevant factors.

Design

Cross‐sectional online survey.

Methods

We developed a questionnaire, addressing registration, professional experiences, anticipations, and internal and external factors that might affect the decision of inactive nurses to return to nursing during the pandemic. Between 27 April and 15 June 2020, we recruited participants in Germany via social networks, organizations and institutions and asked them to forward the link to wherever other inactive nurses might be reached.

Results

Three hundred and thirty‐two participants (73% female) could be included in the analysis. The majority of the participants (n = 262, 79%) were general nurses. The main reason for registering was ‘want to do my bit to manage the crisis’ (n = 73, 22.8%). More than two thirds of the participants (n = 230, 69%) were not or not yet registered. One hundred and twelve (49%) out of 220 participants, who gave reasons why they did not register, selected they ‘could not see a necessity at that time’. The few inactive nurses who were deployed reported a variety of experiences.

Conclusions

Different factors influence the nurses’ decision to register or not. A critical factor for their decision was previous experiences that had made them leave the job and prevented a return—even for a limited time in a special situation.

Impact

From the responses of the participants in this study, it can be deduced that: negative experiences made while working in nursing influence the willingness to volunteer for a deployment; only one‐third of the inactive nurses would be willing to return to the nursing profession to help manage the Corona pandemic; policymakers and nursing leaders should not rely on the availability of inactive nurses in a crisis.

Returning home: The role of expectations in re-entry adaptation

Returning home after a study abroad experience can be challenging. In the current research, we examine the discrepancy between adaptation expectations and experience in a longitudinal sojourner study (N = 1319; M_age = 17 years; 70% female). Returnees adaptation expectations were assessed prior to returning home, followed by post return measures of adaptation experiences and general well‐being. Overall, returnees reported higher levels of re‐entry adaptation than anticipated. According to the accuracy hypothesis, unmet expectations will be associated with lower well‐being. In contrast, the directional hypothesis suggests that unmet expectations will negatively impact on well‐being, but only if the expectation is undermet. Well‐being on return was regressed on pre‐travel adaptation expectations and adaptation experience on re‐entry. Polynomial regression and Response Surface Analyses were conducted for two outcome variables (stress and satisfaction with life), two types of adaptation (psychological and sociocultural), and at different time points (approximately 2 weeks and 6 months after return). Results consistently show that larger discrepancies were associated with lower well‐being for negative mismatches (when expectations were undermet). For positive mismatches, if adaptation was better than expected, well‐being was higher. Congruence between expectation and experience were not associated with well‐being. Thus, across analyses, results supported a directional hypothesis.

Return visit characteristics of SARS-CoV-2 PCR-positive cases in a pediatric emergency department

BACKGROUND

The aim of this study was to evaluate return visits to the pediatric emergency department (ED) for children who were detected to be positive for SARS-CoV-2 by polymerase chain reaction (PCR).

METHODS

Between April 2, 2020, and January 20, 2021, children aged 0 to 18 years who were detected to be SARS-CoV-2 PCR-positive and discharged from the ED were evaluated. Among them, patients who returned to the ED within 14 days of quarantine were included in the study. For the first presentation and return visit, demographics, clinical findings, laboratory and radiologic investigations, and ward/pediatric intensive care unit (PICU) admissions were recorded. Patients were divided into 5 groups according to clinical severity.

RESULTS

Among 575 children who were confirmed to be SARS-CoV-2 PCR-positive, 50 (8.6%) of them [median age: 10.4 years (IQR: 4.8-15.2); 26 females] had returned. There was no difference for age, sex, underlying diseases, or symptoms for patients who returned or did not for the first presentation, but the percentage of those from whom laboratory tests were obtained was higher in cases of return visits. For symptomatic cases on the first presentation, the most common reason for return was having additional symptoms. The most common symptoms at the return visit were fever, cough, and sore throat. There was no severe/critical case in terms of clinical severity. Among all cases, 36 (72.0%) patients were discharged from the ED, 13 (26.0%) were observed for 6-8 h and then discharged, and 1 (2.0%) was admitted to the ward; there was no PICU admission or death, respectively.

Effect of total hip arthroplasty on brake reaction time and braking force

INTRODUCTION

The correct moment for return to driving after total hip arthroplasty (THA) remains unclear. Until today no uniform recommendation exists on the ability to perform an emergency brake.The aim of this prospective study was to investigate the braking ability of patients before and after THA implantation based on brake reaction time in milliseconds (BRT) and braking force in N (BF).

METHODS

In total, 25 patients (15 men, 10 women, mean age 51.3 ± 10.1 years) were treated with THA on the right side. Inclusion criteria consisted of a valid driving licence, frequent road participation and at least 2 years of driving experience. Exclusion criteria were underlying neurological disorders as well as severe complaints in the lumbar spine and the right knee joint. The brake ability was evaluated for emergency braking with a car simulator and a measuring sole. Measurements were performed preoperatively, 6 days, 2, 4 and 6 weeks after surgery.

RESULTS

Preoperatively, the mean BRT was 671.3 ± 123.5 ms and the BF 455.4 ± 185.0 N. Significant differences were observed at 6 days and 2 weeks after surgery, (BRT 836.4 ± 219.7 ms, respectively, BRT 735.0 ± 186.7 ms, and BF 302.6 ± 154.9 N, respectively, BF 375.5 ± 149.3 N, p < 0.05). Only 4 weeks after, no significant differences were seen compared to pre-operative with a BRT of 647.0 ± 91.9ms (p = 0.354) and BF of 435.9 ± 177.4 (p = 0.843). Furthermore, the BRT improved significantly after 6 weeks (607.4 ± 87.6; p = 0.005).

CONCLUSIONS

The braking force is significantly reduced, and the brake reaction time is prolonged directly after surgery for at least 2 weeks. After 4 weeks, no statistically significant differences were measured, although special care should still be taken during return to activity.

Risk factors for unplanned return to the operating room within 24 hours: A 9-year single-center observational study

The purpose of the retrospective case-control study was to identify the causes of and risk factors for unplanned return to the operating room (uROR) within 24 hours in surgical patients.We examined 275 cases of 24-hour uROR in our hospital from January 2010 to December 2018. The reasons for 24-hour uROR were classified into several categories. Controls were randomly matched to cases in a 1:1 ratio with the selection criteria set for the same surgeon and operation code in the same corresponding year.The mortality rate was significantly higher in patients with 24-hour uROR (11.63% vs 5.23%). Bleeding was the most common etiology (172/275; 62.55%) and technical error (14.5%) also contributed to 24-hour uROR. The clinical factors that led to bleeding included a history of liver disease (P = .032), smoking (P = .002), low platelet count in preoperative screening (P = .012), and preoperative administration of antiplatelet or anticoagulant agents (P = .014).Clinicians should recognize the risk factors for bleeding and minimize errors to avoid the increase in patient morbidity and mortality that is associated with 24-hour uROR.Level of Evidence: Level IV.

Portfolio Optimization with a Mean-Absolute Deviation-Entropy Multi-Objective Model

Investors wish to obtain the best trade-off between the return and risk. In portfolio optimization, the mean-absolute deviation model has been used to achieve the target rate of return and minimize the risk. However, the maximization of entropy is not considered in the mean-absolute deviation model according to past studies. In fact, higher entropy values give higher portfolio diversifications, which can reduce portfolio risk. Therefore, this paper aims to propose a multi-objective optimization model, namely a mean-absolute deviation-entropy model for portfolio optimization by incorporating the maximization of entropy. In addition, the proposed model incorporates the optimal value of each objective function using a goal-programming approach. The objective functions of the proposed model are to maximize the mean return, minimize the absolute deviation and maximize the entropy of the portfolio. The proposed model is illustrated using returns of stocks of the Dow Jones Industrial Average that are listed in the New York Stock Exchange. This study will be of significant impact to investors because the results show that the proposed model outperforms the mean-absolute deviation model and the naive diversification strategy by giving higher a performance ratio. Furthermore, the proposed model generates higher portfolio mean returns than the MAD model and the naive diversification strategy. Investors will be able to generate a well-diversified portfolio in order to minimize unsystematic risk with the proposed model.

Return to Work Following Total Knee and Hip Arthroplasty: The Effect of Patient Intent and Preoperative Work Status

BACKGROUND

The ability of total knee and hip arthroplasty (TKA/THA) to facilitate return to work (RTW) when it is the patient's preoperative intent to do so remains unclear. We aimed at determining whether TKA/THA facilitated RTW in patients of working age who intended to return.

METHODS

This is a prospective cohort study of 173 consecutive patients <65 years of age, undergoing unilateral TKA (n = 82: median age 58; range, 39-65; 36 [43.9%] male) or THA (n = 91: median age 59; range, 34-65; 42 [46.2%] male) during 2018. Oxford knee/hip scores, Oxford-Activity and Participation Questionnaire, and EuroQol-5 dimension (EQ-5D) scores were measured preoperatively and at 1 year when an employment questionnaire was also completed.

RESULTS

Of patients who intended to RTW, 44 of 52 (84.6%) RTW by 1 year following TKA (at mean 14.8 ± 8.4 weeks) and 53 of 60 (88.3%) following THA (at mean 13.6 ± 7.5 weeks). Failure to RTW despite intent was associated with job physicality for TKA (P = .004) and negative preoperative EQ-5D for THA (P = .01). In patients unable to work before surgery due to joint disease, fewer RTW: 4 of 21 (19.0%) after TKA; and 6 of 17 (35.3%) after THA. Preoperative Oxford knee score >18.5 predicted RTW with 74% sensitivity (P < .001); preoperative Oxford hip score >19.5 predicted RTW with 75% sensitivity (P < .001). Preoperative EQ-5D indices were similarly predictive (P < .001).

CONCLUSION

In this United Kingdom study, preoperative intent to RTW was the most powerful predictor of actual RTW following TKA/THA. Where patients intend to RTW following TKA/THA, 85% RTW following TKA and 88% following THA.

Return of results in a global survey of psychiatric genetics researchers: practices, attitudes, and knowledge

PURPOSE

Patient-participants in psychiatric genetics research may be at an increased risk for negative psychosocial impacts related to the return of genetic research results. Examining psychiatric genetics researchers' return of results practices and perspectives can aid the development of empirically informed and ethically sound guidelines.

METHODS

A survey of 407 psychiatric genetics researchers from 39 countries was conducted to examine current return of results practices, attitudes, and knowledge.

RESULTS

Most respondents (61%) reported that their studies generated medically relevant genomic findings. Although 24% have returned results to individual participants, 52% of those involved in decisions about return of results plan to return or continue to return results. Respondents supported offering "medically actionable" results related to psychiatric disorders (82%), and the majority agreed non-medically actionable risks for Huntington (71%) and Alzheimer disease (64%) should be offered. About half (49%) of respondents supported offering reliable polygenic risk scores for psychiatric conditions. Despite plans to return, only 14% of researchers agreed there are adequate guidelines for returning results, and 59% rated their knowledge about how to manage the process for returning results as poor.

CONCLUSION

Psychiatric genetics researchers support returning a wide range of results to patient-participants, but they lack adequate knowledge and guidelines.

Predictive Factors for Return to Driving following Volar Plate Fixation of Distal Radius Fracture

Background  A common query by patients undergoing distal radius fracture (DRF) repair is when (s)he can resume driving postoperatively. A prospective cohort analysis was performed to assess fracture and patient factors on a patient's self-reported ability to return to driving to better inform patients and surgeons. Methods  Consecutive patients undergoing DRF repair with locking volar plate were enrolled. Preoperative demographic and radiographic characteristics, and postoperative time to return to driving were collected. Data collected included age, sex, hand dominance, body mass index (BMI), level of education, concomitant ulnar fracture, fracture setting prior to surgery, and AO fracture classification. Results  A total of 131 patients were enrolled (108 women, 23 men) with 36 AO type A, 22 AO type B, and 73 AO type C DRFs, with an average age of 59.5 years. Fracture severity by classification did not significantly affect time to return to driving. However, BMI, sex, and age were found to significantly affect time to return to driving. Patients aged 19 to 59 years, 60 to 75 years, and over 75 years returned to driving 13.1, 15.4, and 30.1 days following surgery, respectively ( p  < 0.01). Classified by BMI, patients that were normal weight, overweight, and obese returned to driving 11.5, 13.1, and 21.0 days following surgery, respectively ( p  < 0.05). Men returned to driving 8.8 days and women 17.3 days postoperatively ( p  = 0.001). Conclusion  Patients severity of fracture as determined by AO fracture type did not affect time to driving, while increased BMI, female sex, and increased age were found to be significant factors in patients' return to driving time after distal radius fracture repair. Level of Evidence  This is a Level II, prospective cohort study.

Pressure and flow properties of cannulae for extracorporeal membrane oxygenation I: return (arterial) cannulae

Adequate extracorporeal membrane oxygenation support in the adult requires cannulae permitting blood flows up to 6-8 L/minute. In accordance with Poiseuille's law, flow is proportional to the fourth power of cannula inner diameter and inversely proportional to its length. Poiseuille's law can be applied to obtain the pressure drop of an incompressible, Newtonian fluid (such as water) flowing in a cylindrical tube. However, as blood is a pseudoplastic non-Newtonian fluid, the validity of Poiseuille's law is questionable for prediction of cannula properties in clinical practice. Pressure-flow charts with non-Newtonian fluids, such as blood, are typically not provided by the manufacturers. A standardized laboratory test of return (arterial) cannulae for extracorporeal membrane oxygenation was performed. The aim was to determine pressure-flow data with human whole blood in addition to manufacturers' water tests to facilitate an appropriate choice of cannula for the desired flow range. In total, 14 cannulae from three manufacturers were tested. Data concerning design, characteristics, and performance were graphically presented for each tested cannula. Measured blood flows were in most cases 3-21% lower than those provided by manufacturers. This was most pronounced in the narrow cannulae (15-17 Fr) where the reduction ranged from 27% to 40% at low flows and 5-15% in the upper flow range. These differences were less apparent with increasing cannula diameter. There was a marked disparity between manufacturers. Based on the measured results, testing of cannulae including whole blood flows in a standardized bench test would be recommended.

Return for prenatal care and childbirth services among Nigerian women using primary health care facilities

Aim

The study assessed the return for prenatal care and childbirth services among Nigerian women using primary health care facilities.

Design

A descriptive cross-sectional approach was employed for the study.

Methods

A total of 730 participants randomly recruited systematically from 21 purposively selected primary health care facilities in Ibadan, Nigeria were studied. A questionnaire and a checklist were used for data collection. The collection of data spanned three months (April to June, 2014). The data were analysed descriptively and inferentially while the results were presented in frequency tables.

Results

The women's mean age was 28 ± 5.3 years. Out of the 730 women studied, 92.6% received prenatal care. The mean difference between the number of prenatal care registration and the number of childbirths was 76.5. Poor environmental hygiene of facilities, statistically significant cost of services and non-availability of 24-hr service were implicated for dissatisfaction with care received by the women and consequent poor return rate for childbirth.

Return to sport following surgical management of triangular fibrocartilage tears: a systematic review

INTRODUCTION

This review aims to provide information on return rates and times to return to sport following surgical management of triangular fibrocartilage (TFC) tears.

SOURCES OF DATA

A systematic search of CINAHAL, Cochrane, EMBASE, Google Scholar, Medline, PEDro, Scopus, SPORTDiscus and Web of Science was performed using the keywords 'triangular', 'fibro-cartilage', 'complex', 'tear', 'distal radio-ulnar joint', 'athletes', 'sports', 'non-operative', 'conservative', 'operative' and 'return to sport'.

AREAS OF AGREEMENT

In all of the 10 studies included, conservative management for 6 weeks to 6 months was the first-line treatment. If symptoms persisted following this period, surgical management was advised. Arthroscopic debridement was recommended for central tears, and arthroscopic repair was recommended for peripheral tears.

AREAS OF CONTROVERSY

The optimal treatment modalities for TFC tears remain to be defined.

GROWING POINTS

Traumatic central tears can be treated with arthroscopic debridement alone. Arthroscopic repair with an all-inside repair can improve return rates to sport over an outside-in technique for ulna-sided tears.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future prospective studies should aim to establish the optimal treatment modalities for TFC tears.

Cat Colony Caretakers' Perceptions of Support and Opposition to TNR

Trap, neuter and return (TNR) is a non-lethal approach to urban cat management used effectively internationally to decrease urban cat numbers, but deemed illegal in Australia. We investigated perceived support and opposition to TNR experienced by respondents involved in TNR activities, as individuals or through organizations. TNR was initiated to reduce cat numbers, as a humane way to manage community cats, and to improve cat welfare. Many respondents sought permission from local authorities, and all received verbal permission. Perceived attitudes of stakeholders, for example authorities and neighbors, were polarized, with some supporting it and others antagonistic and threatening legal action. Respondents generally managed the colony themselves or with assistance from friends or family, and half obtained aid from a cat welfare agency. Some respondents received cash or food from stakeholders, subsidies for desexing and education on trapping. Complaints were most common from neighbors, and less from those working and living nearby the colony. Resolution was attempted with varying success, by face-to-meetings with complainants, educational flyers, cat deterrents, or relocating cats. Supportive stakeholders had similar motives to the respondents for supporting TNR, namely to reduce cat populations and improve cat welfare. These findings are important because they demonstrate the difficulty faced by individuals and organizations undertaking TNR in Australia. Given the reported effectiveness of well-managed TNR programs, and the lack of other acceptable methods for managing urban stray cats at a city level, it is recommended that TNR be legalized in Australia in urban and periurban areas to facilitate its implementation.

Does restaging transurethral resection of bladder tumour influence outcomes in patients treated with BCG immunotherapy? 491 cases in 20 years' experience

Introduction

Bladder cancer is one of the most common malignancies worldwide.

Aim

To analyse the influence of restaging transurethral resection of bladder tumour (reTURB) on outcomes in patients treated with BCG immunotherapy.

Material and methods

We analysed a database of 491 patients who were treated in a Bacillus Calmette-Guérin (BCG) outpatient department between 1998 and 2016. A minimum of 12 months of follow-up was required. The study included 235 patients with a history of the reTURB procedure and 256 patients without reTURB. The patients were analysed in terms of recurrence-free (RFS), progression-free (PFS), cancer-specific and overall survival.

Results

The RFS was significantly higher in the reTURB group for both general and subgroup analysis (T1HG, TaHG). The PFS was significantly higher in the reTURB group for both general and subgroup analysis (TaHG). In patients without lamina muscularis in the specimen there was a greater improvement in RFS due to the reTURB procedure than for other patients. ReTURB performed in T1 tumours with massive lamina propria infiltration had a positive influence on RFS. In patients with reTURB the presence of focal invasion was related to lower risk of progression. Both overall and cancer-specific survival were significantly improved by the reTURB procedure in T1HG and HG tumours.

Conclusions

This study highlights the importance of reTURB. It was found that the patients with TaHG tumours benefited the most in terms of RFS, PFS and cancer-specific survival. It was also demonstrated that massive lamina propria infiltration in T1 tumours is associated with the worst outcomes.

Risk-Return Analysis of the Biopharmaceutical Industry as Compared to Other Industries

Background: Profits in the biopharmaceutical industry have been scrutinized in social debate. However, drawing conclusions based on industry profitability only is inappropriate as such an analysis does not account for risks faced by investors. This study aims to measure risks and returns in the biopharmaceutical industry and investigates whether risk-adjusted return on investment in the biopharmaceutical industry is higher than that in other industries.

Methods: To enable appropriate comparison, we identified six benchmark industries with characteristics that match those of the biopharmaceutical industry: automotive manufacturing, commercial aircraft manufacturing, consumer electronics, packaged food manufacturing, telecom, and oil and gas. For those industries, we selected the top 25 companies per industry, covering 35–65% of industry revenues. Data on return measures (i.e., net profit margin, return on equity, total shareholder return) and risk measures (i.e., volatility of total shareholder return, beta) were derived from Bloomberg over the 2004–2016 period. The Sharpe ratio was calculated as a measure of risk-adjusted return on investment and compared between industries.

Results: Net profit margins varied between 12.6 and 19.5% in the biopharmaceutical industry, and ranged from 2.6 to 8.4% in the benchmark industries. Return on equity for the biopharmaceutical industry was above the average for the other industries. Total shareholder returns for the biopharmaceutical industry amounted to 11.7%, ranking fifth across the seven industries. The biopharmaceutical industry ranked sixth among the seven industries regarding beta, and sixth in terms of volatility of total shareholder return. The median Sharpe value for the biopharmaceutical industry ranked fifth of seven industries.

Conclusion: Over the 2004–2016 period, the biopharmaceutical industry did not attain risk-adjusted return on investment in excess of that in other industries and, thus, did not outperform these industries.

Return to sport following arthroscopic Bankart repair: a systematic review

HYPOTHESIS AND BACKGROUND

The purpose of this systematic review was to determine the return-to-sport rate following arthroscopic Bankart repair, and it was hypothesized that patients would experience a high rate of return to sport.

METHODS

The MEDLINE, Embase, and PubMed databases were searched by 2 reviewers, and the titles, abstracts, and full texts were screened independently. The inclusion criteria were English-language studies investigating arthroscopic Bankart repair in patients of all ages participating in sports at all levels with reported return-to-sport outcomes. A meta-analysis of proportions was used to combine the rate of return to sport using a random-effects model.

RESULTS

Overall, 34 studies met the inclusion criteria, with a mean follow-up time of 46 months (range, 3-138 months). The pooled rate of return to participation in any sport was 81% (95% confidence interval [CI], 74%-87%). In addition, the pooled rate of return to the preinjury level was 66% (95% CI, 57%-74%) (n = 1441). Moreover, the pooled rate of return to a competitive level of sport was 82% (95% CI, 79%-88%) (n = 273), while the pooled rate of return to the preinjury level of competitive sports was 88% (95% CI, 66%-99%).

CONCLUSION

Arthroscopic Bankart repair yields a high rate of return to sport, in addition to significant alleviation of pain and improved functional outcomes in the majority of patients. However, approximately one-third of athletes do not return to their preinjury level of sports.

Successful Return to Sport After Arthroscopic Shoulder Stabilization Versus Nonoperative Management in Contact Athletes With Anterior Shoulder Instability: A Prospective Multicenter Study

BACKGROUND

The debate continues regarding the optimal treatment of intercollegiate contact athletes with in-season anterior shoulder instability.

PURPOSE

To examine return to sport and recurrent instability in the season after the index in-season anterior instability event.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Forty-five contact intercollegiate athletes treated nonoperatively or with arthroscopic stabilization were prospectively followed in a multicenter observational study to evaluate return to play (RTP) and recurrent instability in the season after an initial in-season anterior glenohumeral instability event. Baseline data collection included sport played, previous instability events, direction of instability, type of instability (subluxation or dislocation), and treatment method (nonoperative management or arthroscopic stabilization). All nonoperatively treated athletes underwent a standardized accelerated rehabilitation program without shoulder immobilization. Surgical stabilization was performed arthroscopically in all cases, and successful RTP was evaluated during the next competitive season after complete rehabilitation.

RESULTS

Thirty-nine of 45 intercollegiate contact athletes had remaining National Collegiate Athletic Association eligibility and were followed through the subsequent competitive season after the index instability event. Of the 10 athletes electing nonoperative treatment, 4 (40%) successfully returned to play without recurrence during the subsequent season. Of the 29 athletes treated surgically, 26 (90%) were able to successfully return to play without recurrence the following season (recurrence: n = 1; inadequate function: n = 2). Athletes who underwent surgical reconstruction before the next season were 5.8 times (95% CI, 1.77-18.97; P = .004) more likely to complete the subsequent season without recurrent instability. Of the 29 athletes electing surgical stabilization, there was no difference (risk ratio, 0.95; 95% CI, 0.10-9.24; P > .99) in RTP between the 9 stabilized after a single instability event (90% RTP rate) and the 20 stabilized after multiple in-season recurrent instability events (89% RTP rate).

CONCLUSION

Collegiate contact and collision athletes with in-season anterior shoulder instability are significantly more likely to successfully return to sport without subsequent instability events the next season if they undergo surgical repair in the off-season.

Impacts of Encouraging Dog Walking on Returns of Newly Adopted Dogs to a Shelter

This study involved examining the ability of a postadoption intervention to reduce returns of newly adopted dogs to shelters by encouraging physical activity between adopters and their dogs. Guardians in the intervention group received emails with dog behavior and human activity advice as well as invitations to join weekly dog walks. Both the intervention and control groups completed surveys regarding outdoor activity with their dogs, their dog-walking habits, and perceptions of their dogs' behaviors. Adopter-dog pairs in the intervention group were not significantly more active than those in the control group, nor did they show a reduced incidence of returning their dogs. Guardians in both groups who reported higher obligation and self-efficacy in their dog walking were more active regardless of experimental condition; however, obligation, dog-walking self-efficacy, and perceptions about their dogs' on-leash behaviors did not predict rates of return to the shelter. These findings add to the understanding of shelter dog re-relinquishment and the effective utilization of resources postadoption, and they indicate further research is needed to address the complexities of this newly forming human-dog relationship.

Trap-Neuter-Return Activities in Urban Stray Cat Colonies in Australia

Simple Summary

Urban stray cats in Australia are poorly regarded because of wildlife predation and nuisance behaviors. However, current methods of population control via low level culling are ineffective. Effective control requires culling 30% to 50% of the population every six months, which is prohibitive for municipalities. Overseas, trap, neuter and return is frequently used to control urban cat numbers, and reduce nuisance behaviors, but is considered illegal in many Australian jurisdictions. An anonymous questionnaire was used to gather data on trap, neuter and return of urban stray cats in Australia. Respondents were mostly middle-aged women, and more participated as individuals than with organizations. Colony size decreased from a median of 11.5 cats to 6.5 cats over 2.2 years, through adoptions and desexing a median of 69% of the colony. Cats were fed once or twice daily, and provided with prophylactic health care. Programs were largely funded by private sources, with some funding by animal welfare organizations. We conclude that trap, neuter and return associated with high desexing rates in colonies, and adoption of kittens and friendly adults substantially reduces colony size, and improves the welfare of cats and kittens. This model is cost-effective for municipalities, and should be legalized in Australia.

Abstract

Trap, neuter and return (TNR) describes a non-lethal approach to the control of urban stray cat populations. Currently, in Australia, lethal control is common, with over 85% of cats entering some municipal pounds euthanized. No research has been published describing TNR activities in Australia. Adults involved with TNR in Australia were invited to participate. Data from 53 respondents were collected via an anonymous online questionnaire. Most respondents were females 36 to 65 years of age, and slightly more participated in TNR as individuals than as part of an organization. Respondents generally self-funded at least some of their TNR activities. The median number of colonies per respondent was 1.5 (range 1 to over 100). Median colony size declined from 11.5 to 6.5 cats under TNR over a median of 2.2 years, and the median percent reduction was 31%; this was achieved by rehoming cats and kittens and reducing reproduction. A median of 69% of cats in each colony were desexed at the time of reporting. Most respondents fed cats once or twice daily, and at least 28% of respondents microchipped cats. Prophylactic healthcare was provided to adult cats and kittens, commonly for intestinal parasites (at least 49%), and fleas (at least 46%); vaccinations were less common. Time-consuming activities for respondents were feeding (median 4 h/week) and locating resources (median 1.1 h/week). These findings indicate that TNR, when involving high desexing rates within colonies, adoption of kittens and friendly adults, and ongoing oversight by volunteer caretakers, can reduce cat numbers over time, improve health and welfare of cats and kittens, and is largely funded by private individuals and organizations.

Return to sport following stress fractures of the great toe sesamoids: a systematic review

INTRODUCTION

This review aims to provide information on return rates and times to sport following stress fractures of the great toe sesamoids (SFGTSs).

SOURCES OF DATA

A systematic search of CINAHAL, Cochrane, EMBASE, Google Scholar, Medline, PEDro, Scopus, SPORTDiscus and Web of Science was performed using the keywords 'stress', 'fractures', 'great', 'toe', 'sesamoid', 'athletes', 'sports', 'non-operative', 'conservative', 'operative' and 'return to sport'.

AREAS OF AGREEMENT

Fourteen studies were included: three studies reported on the outcome of conservatively-managed SFGTSs; thirteen studies reported on the outcome of surgically-managed SFGTSs. The management principles were to attempt conservative management for 2-6 months using activity modification, analgesia, orthotics and physiotherapy; if symptoms persisted following this, surgical management was to be recommended, either with internal fixation or sesamoidectomy.

AREAS OF CONTROVERSY

The optimal treatment modalities for SFGTSs remain to be defined.

GROWING POINTS

Internal fixation shows the best return to full-level sport rates with low rates of complications.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future prospective studies should aim to establish the optimal treatment modalities for SFGTSs.

Return to sport following clavicle fractures: a systematic review

INTRODUCTION

This review aims to provide information on the return rates and return times to sport following clavicle fractures.

SOURCES OF DATA

A systematic search of Medline, EMBASE, CINAHAL, Cochrane, Web of Science, PEDro, SPORTDiscus, Scopus and Google Scholar was performed using the keywords 'clavicle', 'clavicular', 'fractures', 'athletes', 'sports', 'non-operative', 'conservative', 'operative', 'return to sport'.

AREAS OF AGREEMENT

Twenty-three studies were included: 10 reported on mid-shaft fractures, 14 on lateral fractures. The management principles for athletic patients were to attempt non-operative management for undisplaced fractures to undertake operative intervention for displaced lateral fractures and to recommend operative intervention for displaced mid-shaft fractures.

AREAS OF CONTROVERSY

The optimal surgical modality for mid-shaft and lateral clavicle fractures.

GROWING POINTS

Operative management of displaced mid-shaft fractures offers improved return rates and times to sport compared to non-operative management. Suture fixation and non-acromio-clavicular joint (ACJ)-spanning plate fixation of displaced lateral fractures show promising results.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future prospective studies should aim to establish the optimal treatment modalities for clavicle fractures.

Return to play and recurrent instability after in-season anterior shoulder instability: a prospective multicenter study

BACKGROUND

There is no consensus on the optimal treatment of in-season athletes with anterior shoulder instability, and limited data are available to guide return to play.

PURPOSE

To examine the likelihood of return to sport and the recurrence of instability after an in-season anterior shoulder instability event based on the type of instability (subluxation vs dislocation). Additionally, injury factors and patient-reported outcome scores administered at the time of injury were evaluated to assess the predictability of eventual successful return to sport and time to return to sport during the competitive season.

STUDY DESIGN

Cohort study (prognosis); Level of evidence, 2.

METHODS

Over 2 academic years, 45 contact intercollegiate athletes were prospectively enrolled in a multicenter observational study to assess return to play after in-season anterior glenohumeral instability. Baseline data collection included shoulder injury characteristics and shoulder-specific patient-reported outcome scores at the time of injury. All athletes underwent an accelerated rehabilitation program without shoulder immobilization and were followed during their competitive season to assess the success of return to play and recurrent instability.

RESULTS

Thirty-three of 45 (73%) athletes returned to sport for either all or part of the season after a median 5 days lost from competition (interquartile range, 13). Twelve athletes (27%) successfully completed the season without recurrence. Twenty-one athletes (64%) returned to in-season play and had subsequent recurrent instability including 11 recurrent dislocations and 10 recurrent subluxations. Of the 33 athletes returning to in-season sport after an instability event, 67% (22/33) completed the season. Athletes with a subluxation were 5.3 times more likely (odds ratio [OR], 5.32; 95% CI, 1.00-28.07; P = .049) to return to sport during the same season when compared with those with dislocations. Logistic regression analysis suggests that the Western Ontario Shoulder Instability Index (OR, 1.05; 95% CI, 1.00-1.09; P = .037) and Simple Shoulder Test (OR, 1.03; 95% CI, 1.00-1.05; P = .044) administered after the initial instability event are predictive of the ability to return to play. Time loss from sport after a shoulder instability event was most strongly and inversely correlated with the Simple Shoulder Test (P = .007) at the time of initial injury.

CONCLUSION

In the largest prospective study evaluating shoulder instability in in-season contact athletes, 27% of athletes returned to play and completed the season without subsequent instability. While the majority of athletes who return to sport complete the season, recurrent instability events are common regardless of whether the initial injury was a subluxation or dislocation.

Return of Results from Genomic Sequencing: A Policy Discussion of Secondary Findings for Cancer Predisposition

Advances in DNA sequencing technology now allow for the rapid genome-wide identification of inherited and acquired genetic variants including those that have been identified as pathogenic alleles for a number of diseases including cancer. Whole genome and exome sequencing are increasingly becoming a part of both clinical practice and research studies. In 2013 the American College of Medical Genetics and Genomics (ACMG) recommended that results of pathogenic genetic variants in 56 genes, nearly half of which comprise cancer genes (including BRCA1, BRCA2, TP53, MLH1, MLH2, MSH6, PMS2, and APC),be returned to patients who have their genome sequenced independent of the purpose for the test. This recommendation has been highly controversial for several reasons, particularly the recommendation that individuals be returned secondary findings of disease causing variants for adult onset conditions regardless of age and without consideration of patient preferences. In addition, the policy regarding returning results of secondary findings from genomic sequencing studies in research settings is currently unclear. In response to these emerging ethical issues, the Washington University Brown School in St. Louis, MO, United Stateshosted a policy forum entitled "First do no harm: Genetic privacy in the age of genomic sequencing" on February 25^th, 2014. The forum included a panel of experts to discuss their views on ethical issues related to return of results in both the clinical and research settings. In this report, we highlight key issues related to return of results from genome sequencing tests that emerged during the forum.

Risk factors for return with a second trigger digit

The purpose of this study was to determine predictors of return to the same practice with a second idiopathic trigger digit. A total of 2234 patients with Quinnell grade 2 or greater (objective triggering) of one or more digits were retrospectively analysed. A total of 490 of 2234 (22%) patients returned to the same practice with a second trigger digit, with an average follow-up time of 2.1 years (range, 7 days to 10 years). Predictors of return with a second trigger digit included carpal tunnel syndrome, Type 1 diabetes mellitus and duration of follow-up in years. Patients diagnosed with idiopathic trigger digit can be advised that about one in five will return to the same practice with another trigger digit, with approximately double the risk in patients that have carpal tunnel syndrome or Type 1 diabetes.

Partial anomalous pulmonary venous connections: surgical management

Partial anomalous pulmonary venous connections (PAPVCs) are a heterogeneous group of congenital heart lesions in which at least one pulmonary vein will drain into the systemic venous system. The consequences are a variable left-to-right hemodynamic shunt and more rarely pulmonary artery hypertension. Often, PAPVC occurs in association with other congenital cardiac malformations. Surgical correction is most often advisable and is generally straightforward and simple to achieve. Historically, some repairs have included incision across the junction of the superior vena cava with the right atrium, which can lead to late arrhythmias. The Warden technique avoids incision across the atriocaval junction. Neonates and infants with Scimitar syndrome represent the most challenging subset of patients with PAPVC.

Effects of prior knee surgery on subsequent injury, imaging, and surgery in NCAA collegiate athletes

BACKGROUND

High school and professional athletes with a history of orthopaedic surgery have decreased career lengths and are at a greater risk for reinjury compared with their peers. It is unknown whether the same risk applies to intercollegiate athletes.

PURPOSE

To determine the effect of prior knee surgery in National Collegiate Athletic Association (NCAA) Division I athletes in the United States.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Division I athletes who began participation in collegiate athletics at a single institution from fall 2003 to spring 2008 were identified. Athletes with a history of orthopaedic surgery were identified through preparticipation evaluation forms. Data on the number of seasons and games played, number of days missed, diagnostic imaging, athletic injuries sustained, and surgical operations during college were collected through medical records and the Sports Injury Monitoring System (SIMS).

RESULTS

During the 5-year study period, 456 athletes completed preparticipation evaluation forms. Of these, 104 athletes (22.8%) had a history of orthopaedic surgery (Ortho group). Forty-eight (10.5% of all athletes) had a history of knee surgery (Knee group), 16 (3.5%) had a history of anterior cruciate ligament reconstruction (ACL group), and 28 (6.1%) had a history of multiple surgeries (Multiple group). Days missed per season due to any injury and due to knee injury were increased for all surgical groups compared with controls (P < .016). The rate of knee injury and knee surgery while in college was significantly increased for all surgery groups. Athletes in the Knee and ACL groups were 6.8- and 19.6-fold more likely to sustain a knee injury and 14.4- and 892.9-fold more likely to undergo a knee surgery during their collegiate careers compared with controls (P < .001). The number of MRIs per season were 0.83 for the Knee group (P < .001), 1.29 for the ACL (P = .009), and 0.97 for the Multiple group (P < .001), compared with 0.37 for controls. Average career length and percentage of games played were not significantly different between any of the surgery groups compared with controls.

CONCLUSION

Athletes who had a history of knee surgery before participation in collegiate athletics miss more days due to injury, have increased rates of knee injury and knee surgery, and require more MRIs during their collegiate careers than their peers.