High Rates Of Dissatisfaction Research Articles

Posterior tibial slope influences joint mechanics and soft tissue loading after total knee arthroplasty.

As a solution to restore knee function and reduce pain, the demand for Total Knee Arthroplasty (TKA) has dramatically increased in recent decades. The high rates of dissatisfaction and revision makes it crucially important to understand the relationships between surgical factors and post-surgery knee performance. Tibial implant alignment in the sagittal plane (i.e., posterior tibia slope, PTS) is thought to play a key role in quadriceps muscle forces and contact conditions of the joint, but the underlying mechanisms and potential consequences are poorly understood. To address this biomechanical challenge, we developed a subject-specific musculoskeletal model based on the bone anatomy and precise implantation data provided within the CAMS-Knee datasets. Using the novel COMAK algorithm that concurrently optimizes joint kinematics, together with contact mechanics, and muscle and ligament forces, enabled highly accurate estimations of the knee joint biomechanics (RMSE <0.16 BW of joint contact force) throughout level walking and squatting. Once confirmed for accuracy, this baseline modelling framework was then used to systematically explore the influence of PTS on knee joint biomechanics. Our results indicate that PTS can greatly influence tibio-femoral translations (mainly in the anterior-posterior direction), while also suggesting an elevated risk of patellar mal-tracking and instability. Importantly, however, an increased PTS was found to reduce the maximum tibio-femoral contact force and improve efficiency of the quadriceps muscles, while also reducing the patellofemoral contact force (by approximately 1.5% for each additional degree of PTS during walking). This study presents valuable findings regarding the impact of PTS variations on the biomechanics of the TKA joint and thereby provides potential guidance for surgically optimizing implant alignment in the sagittal plane, tailored to the implant design and the individual deficits of each patient.

Predictors of Job Satisfaction and Association with Psychological Distress Among Academic Medicine Faculty in Kazakhstan.

The growing concern for the faculty's well-being is allied with the emotionally demanding nature of teaching, which has an adverse effect on physical and mental health. There is abundant evidence that academic medicine faculty are subjected to high rates of dissatisfaction, distress, burnout, and turnover among medical educators. This study is dedicated to the exploration of the association between job satisfaction and psychological distress among academic medicine faculty in Kazakhstan. The observational cross-sectional study was conducted among medical educators in Kazakhstan between 1 October and 25 December. The survey was completed by 715 representatives of academic medicine staff. The sample size was calculated by Epi Info Sample Size Calculator, version 7.0. Multinomial logistic regression analysis using the forced entry procedure was applied to identify the factors associated with job satisfaction. The prevalence of job satisfaction, depression, anxiety, and stress was 19.2%, 40.6%, 41.3%, and 53%, respectively. Three variables were significantly associated with job satisfaction: having a partner (AOR=0.79; 95% CI 0.38-1.659), having work experience of 5-10 years (AOR=0.32; 95% CI 0.14-0.74), and holding a Ph.D. degree (AOR=0.40; 95% CI 0.18-0.91). Job satisfaction was significantly associated with depression (p=0.005) and stress (p<0.001). Compared to previous research in this area, our findings reported a higher prevalence of psychological distress and dissatisfaction. Potential reason for higher rates of dissatisfaction may be the global disruption due to COVID-19 pandemic.

Ten Flaws of Systematic Mechanical Alignment Total Knee Arthroplasty

Mechanical alignment (MA) and its tenets have been considered essential for total knee arthroplasty (TKA) success since they were introduced in 1973. However, over time, there have been colossal advances in our knowledge and understanding of the anatomy and kinematics of the knee, as well as in surgical precision and implants. However, the MA systematic principles of prosthetic arthroplasty and implant position related to the lower-extremity mechanical axis, have only recently been called into question. The high rates of dissatisfaction and residual pain reported after MA TKA prompted this questioning, and that leaves plenty of room for improvement. Despite the general consensus that there is great variability between patients’ anatomy, it is still the norm to carry out a systematic operation that does not consider individual variations. Evolving to a more personalized arthroplasty surgery was proposed as a rational and reasonable option to improve patient outcomes. Transitioning to a personalized TKA approach requires questioning and even disregarding certain MA TKA principles. Based on current knowledge, we can state that certain principles are erroneous or unfounded. The aim of this narrative review was to discuss and challenge 10 previously accepted, yet we believe, flawed, principles of MA, and to present an alternative concept, which is rooted in personalized TKA techniques.

Ethical and Professional Dilemmas encountered by Doctors in the National Health Insurance System

Background: The implementation of the National Health Insurance System in Indonesia has not only increased access to medical services but also raised various dilemmas among doctors. Objective: This study aims to analyse various ethical and professional dilemmas among physicians in the National Health Insurance System (NHIS).Methods: This is a cross-sectional descriptive study with a purposive sampling method. A questionnaire was distributed online between June to December 2019 to physicians practicing in Indonesia.Results: Of the 87 doctors who participated in this study, 60.92% were general practitioners and 39.08% were specialists. The inability to maintain professional independence (63.41%) is the most common ethical dilemma faced by doctors with 65.38% of them experienced in advanced level health facilities. Meanwhile, the limitation of adequate medical care in an emergency (25.45%) is the most dilemmatic situation experienced in terms of professionalism with 85.71% occurring in advanced level health facilities.Conclusion: Physicians in Indonesia were deal with various dilemmas while practicing in the NHIS. The high rate of dissatisfaction and the various ethical problems and professional disciplines require a review of the health system to improve the quality of services and maintain the professionalism of doctors.

A tool for measuring mental workload during prosthesis use: The Prosthesis Task Load Index (PROS-TLX).

When using a upper-limb prosthesis, mental, emotional, and physical effort is often experienced. These have been linked to high rates of device dissatisfaction and rejection. Therefore, understanding and quantifying the complex nature of workload experienced when using, or learning to use, a upper-limb prosthesis has practical and clinical importance for researchers and applied professionals. The aim of this paper was to design and validate a self-report measure of mental workload specific to prosthesis use (The Prosthesis Task Load Index; PROS-TLX) that encapsulates the array of mental, physical, and emotional demands often experienced by users of these devices. We first surveyed upper-limb prosthetic limb users who confirmed the importance of eight workload constructs taken from published literature and previous workload measures. These constructs were mental demands, physical demands, visual demands, conscious processing, frustration, situational stress, time pressure and device uncertainty. To validate the importance of these constructs during initial prosthesis learning, we then asked able-bodied participants to complete a coin-placement task using their anatomical hand and then using a myoelectric prosthesis simulator under low and high mental workload. As expected, using a prosthetic hand resulted in slower movements, more errors, and a greater tendency to visually fixate the hand (indexed using eye-tracking equipment). These changes in performance were accompanied by significant increases in PROS-TLX workload subscales. The scale was also found to have good convergent and divergent validity. Further work is required to validate whether the PROS-TLX can provide meaningful clinical insights to the workload experienced by clinical users of prosthetic devices.

Portable Video Media: Improving The Induction of Labour Journey

Rates of induction of labour (IOL) in the United Kingdom continue to rise. However, research continues to identify high rates of dissatisfaction including information that is shared with women and birthing people prior to making an informed decision. This paper explores the use of portable video media to enhance and complement counselling for IOL with the aim of providing consistent and accurate messages to improve the overall experience.

A ROOT CAUSE ANALYSIS OF DISSATISFACTION IN PATIENTS UNDERGOING SUBACROMIAL DECOMPRESSION SURGERY

Sub-acromial decompression surgery (SAD) has been widely used to treat shoulder impingement. Its validity has been questioned in multi-centric clinical trials and dissatisfaction rates can be high (35%). It is difficult to predict which patients will benefit operatively as research into predictive factors is limited. The study aim was to conduct a root-cause analysis of reasons for dissatisfaction in a cohort of operated patients.All patients with SAD dissatisfaction in the local Upper Limb database between 2015-19 (n=74/296) formed our study cohort. Patients were scored on Oxford shoulder score (OSS), QuickDASH score, EQ-5D-3L (TTO+VAS) at weeks 26 and 52 post-operatively. Patients' clinical history, radiographs, consultation and operative notes were reviewed.28% of patients were dissatisfied with surgery. Mean age =52.3±13.4 years with equal gender distribution. 87% were operated arthroscopically. 67% were in physically demanding occupations. There was a significant increase in OSS and QuickDASH at weeks 26 and 52 post-operatively (p&lt;0.05), similar improvement was not noted in VAS pain score. Pain followed by stiffness were the main contributors of dissatisfaction. Multiple implicating factors were noted, the most common being acromio-clavicular joint arthritis (25.7%), suggesting concomitant pathologies as an additional cause for patient dissatisfaction.This is the first study to evaluate reasons for dissatisfaction following SAD. We noted high rates (28%) of dissatisfaction and a predilection for those involved in physically demanding occupations. We recommend meticulous pre-operative workup to identify co-existing pathologies and appropriate pre-operative counselling to improve outcomes in selected patients needing SAD following failure of conservative management.

Body image dissatisfaction: A novel predictor of poor quality of life in epilepsy

ObjectivePeople with epilepsy have long reported reduced quality of life (QoL) compared to healthy peers. This initial study seeks to broaden our understanding of QoL in adults with epilepsy, by examining the adverse impact of body image dissatisfaction for the first time. This aim stems from the observation that both seizures and their medical treatment can cause unwanted changes to physical appearances, such as weight change, hirsutism, and acne. MethodSixty-three adults with epilepsy and 48 age- and gender-matched healthy controls were recruited from a tertiary epilepsy program and targeted social media. Participants completed an online suite of well-validated questionnaires canvassing state (current) and trait (long-term) aspects of body image dissatisfaction, mood, QoL, and medical history. ResultsPeople with epilepsy reported significantly elevated levels of trait body image dissatisfaction compared to controls across the dimensions of appearance evaluation, body areas satisfaction, and self-classified weight (p = 0.02); but did not differ from controls on state body image dissatisfaction (p > 0.05). All facets of body image dissatisfaction in participants with epilepsy were strongly associated with reduced QoL, together with heavier body weight, depressive symptoms, medical comorbidities, and a belief that epilepsy hindered their ability to attain a healthier physique. Multiple regression revealed that body image dissatisfaction was the strongest unique contributor to poor QoL in the epilepsy group (β = 0.46, p ≤ 0.001), above and beyond the contribution of current depressive symptoms (β = 0.34, p ≤ 0.01). SignificanceThis is the first study to highlight the high rates of body image dissatisfaction among adults with epilepsy, and the significantly detrimental impact it has on patient well-being. It also opens novel avenues for psychological interventions in epilepsy, that focus on enhancing positive body image as a means of holistically improving the often-poor psychological outcomes for people with this condition.

Effect of Pranayama as Adjuvant to Medical Treatment on Severity, Frequency, and Duration of Headache in Migraine Patients: An Open-Label Randomized Controlled Trial.

Migraine is the second leading cause of disability worldwide with high rates of dissatisfaction for allopathic treatment among patients. Pranayama is an easy, convenient, and cost-effective method that can supplement existing standard medical treatment of migraine. To study the effect of pranayama as an adjuvant to standard medical treatment of migraine on clinical outcome variables of migraine. This was a randomized controlled trial conducted on 80 consecutive migraine patients who were diagnosed as per International Classification of Headache Disorders-3 (ICHD-3) criteria and were randomly allocated into two groups, that is, standard medical treatment (SMT) group and standard medical treatment plus pranayama (SMT + P) group. The effect of pranayama on clinical outcome variables of migraine was evaluated by using standardized questionnaires. The data was statistically analyzed using SPSS Statistics 20 software. A P value of ≤0.05 was considered statistically significant. Intragroup analysis showed all clinical outcome variables of migraine reduced significantly in the SMT + P group whereas all clinical outcome variables of migraine except the duration of headache episodes reduced significantly in the SMT group. Although statistically non-significant, intergroup analysis demonstrates that reduction in headache severity, duration of headache episodes, and headache impact test-6 (HIT-6) score was more in the SMT + P group whereas reduction in headache frequency and migraine disability assessment (MIDAS) score was more in the SMT group. Pranayama supplements the standard medical treatment of migraine by reducing the duration of headache episodes in addition to the reduction in headache severity, headache frequency, HIT-6 scores, and MIDAS scores.

Measurement of management and development deficit on sustainability in neighbourhood unit. Case of the new city Ali Mendejeli Constantine

Wastewater and household waste management are among the most significant issues for sustainable districts. Their management requires quantifying spatial relationships between the appreciation spaces rate and well-being. This research aims to quantify the effect of development and management deficits on the sustainability of social housing districts. The case study is the neighbourhood unit in the new Ali Mendjli Constantine, Algeria, characterized by high urban concentration. The critical points marking the latter relate to health and well-being problems. The methodology used in this research is a qualitative survey based on J.P. Thibaud’s commented course approach. It involves the surveyed population selection who create the course according to the issue asked. The results show that more than 50% of the neighbourhood’s spatial configuration directly affects the appropriation feeling, with a high dissatisfaction rate of approximately 85%. Furthermore, the interviewees declared that intermediate spaces within their neighbourhoods are spread over large areas without delimitation and specific development and management, making space assumption difficult. Thus, these spaces become sources of conflict and tension.

137 VIRTUAL CONSULTATIONS IN GERIATRIC MEDICINE OUTPATIENT DEPARTMENTS; THE PERSPECTIVE OF GERIATRIC MEDICINE SPECIALIST TRAINEES

Abstract Background Covid-19 social distancing measures restricted access to outpatient services. “Virtual Clinics”(VCs) were introduced in Outpatients Departments (OPDs) to continue service provision. OPD experience is vital to geriatric medicine training. The geriatric medicine Higher Specialist Training (HST) curriculum requires annual OPD participation. This study sought to identify the impact of VCs on geriatric medicine training. Methods An online mixed-method questionnaire was developed and circulated among geriatric medicine specialist trainees. 20 closed-questions collected demographic information and considered opinion of VCs. 5 open-questions enabled respondents to expand views of VCs. Closed-questions responses underwent quantitative descriptive analysis. Open-question responses underwent qualitative thematic analysis. Results Response rate was 61.4%. 86.3% reported VCs were conducted via telephone calls. 58% didn't feel comfortable conducting VCs. 64.7% didn't feel VCs positively contributed to training. 90.2% stated Face-To-Face (FTF) clinics offer greater training opportunities. 74.51% stated they were less likely to discuss VCs with consultants(compared to FTF clinics). 98.04% hadn't received training in conducting VCs. Qualitative analysis revealed four main themes: (1) Patient Selection: certain patient cohorts are unsuitable for VCs. VCs are useful in relaying simple results; not for patients with complex needs; (2) Practical Considerations: there must be access to required technologies for patients and medical staff. Medicolegal concerns were raised by several respondents; (3) Patient Care: the inability to examine patients is a challenge which impacts patient care. The lack of non-verbal cues impeded communication; (4) Training Impact: Respondents felt VCs weren't beneficial to training. There was a sense that training opportunities had been missed. Conclusion This study found high rates of dissatisfaction with VCs among geriatric trainees. This may be due to: (1) Inadequate training/preparation; (2) Inappropriate patient selection or (3) Lack of video-conferencing technologies. There is a sense that VCs have negatively impacted geriatric medicine training. Current policy advocates for the continuation of VCs. If VCs continue, additional resources may be needed to address any accompanying training deficit.

An integrative review of human-centered design and design thinking for the creation of health interventions.

In the United States, we have a healthcare system crisis with high rates of dissatisfaction among patients and providers. To transform health and healthcare, clinical providers must be proficient in the human-centered approach of design thinking (DT). To synthesize the human-centered design (HCD) and DTliterature for the creation of health interventions. We performed an integrative literature review focused on how HCDand DT are used in the clinical healthcare setting. Four research databases were searched from inception through November 6, 2020. We analyzed the methodology used, who is using the frameworks, and the DT phases included. Twenty-four articles were included in the final analysis. Of the 24 manuscripts, 6 (25%) were nurse-led and 15 (63%) had interdisciplinary first and last authors (e.g., Nursing and Medicine). Overall, 10/24 (42%) included all DT method. When analyzing the articles by approach or methodology, 12 (50%) stated they were using the HCDapproach, 5 (21%) the DT methodology, and 7 (29%) stated they were using both the HCD approach and DT methodology. There are inconsistencies in who uses DT and the phases used to create healthcare interventions.

Risk factors for Burnout Syndrome in healthcare professionals on the front line against Covid-19

The Covid-19 pandemic, since its inception, has been causing serious damage and consequences to the health of the general population. The coronavirus has a high transmission rate and as a result, high rates of infection were obtained, as well as overcrowding in health services. WHO data indicate that most health professionals working on the front line in the fight against the Covid-19 virus, have high rates of anxiety, stress, depression, professional dissatisfaction and feelings of negativism, which negatively influences and causes a decline in health care. service performance. Thus, the objective of this study was to identify, through scientific evidence, which are the risk factors for Burnout Syndrome in health professionals on the front line against Covid-19. For this, an integrative review of the literature was carried out through a survey of data in the scientific bases: LILACS, SCIELO and BRISA. From the analysis of the selected studies, it was possible to identify some factors that emerge risks for the mental health of health professionals. Occupational stress triggered by a long period of exposure to negative emotional stimuli that are generated in the work environment. The findings in the literature indicate that psychic illness has increased in the services, since the Covid-19 virus contributes to this consequence, leaving health professionals exposed to vulnerabilities. Preexisting diseases such as comorbidity, depression, anxiety, mood disorder show as clinically significant indicators that can be a lever for the prevalence of Burnout.

Attitudes Toward Obesity, Willingness to Lose Weight, and Treatment Preferences Among Overweight and Obese Saudi Adults.

Background: Obesity has become a major health concern worldwide and is associated with several diseases and complications. Losing weight is an effective strategy to improve body mass index and prevent the complications of obesity. However, weight loss is dependent on the attitude of individuals toward obesity as well as their willingness to lose weight.Aim: To explore attitudes toward obesity, willingness to lose weight, and treatment preferences among overweight and obese Saudi adults.Methods: An analytical cross-sectional study was conducted among overweight and obese Saudis. We targeted adults aged 18 years and older, who visited family medicine clinics at King Abdulaziz Medical City for the National Guard in Riyadh, Saudi Arabia. The study was conducted from December 2020 to June 2021 using a self-administered questionnaire.Results: Of the 403 participants, 82.5% were dissatisfied with their current body weight. Controlling chronic disease was a major motive for improving body weight (53.2%), and exercise and diet were the most preferred strategies to lose body weight. Age was a determinant in the attitude and willingness of participants to lose weight (p = 0.0001).Conclusion: Participants in the current study reported high dissatisfaction rates about current weight and willingness to improve body weight. This should encourage healthcare providers to initiate weight status discussions and management with their overweight and obese clients.

The Role of Gender Dysphoria in the Development of an Eating Disorder

Back to table of contents Previous article Next article Special Section: Minority Mental Health and DiversityFull AccessThe Role of Gender Dysphoria in the Development of an Eating DisorderEmma Banasiak, B.S.Emma BanasiakSearch for more papers by this author, B.S.Published Online:8 Sep 2022https://doi.org/10.1176/appi.ajp-rj.2022.180104AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Gender dysphoria is a disorder characterized by distress associated with identifying as a gender that differs from one’s sex assigned at birth (1). This distress leads to a higher risk of body image dissatisfaction, which in turn can lead to an increased risk of disordered eating behaviors (2). According to one study, transgender college students were over four times as likely as cisgender heterosexual female college students to be diagnosed as having an eating disorder (2). Some factors commonly seen in the development of eating disorders are a fear of gaining weight, a disturbed perception of one’s own body image, and cultural value placed on thinness as the body ideal (1). These factors tend to affect woman more than men, as reflected in the 10-to-1 female-to-male ratio of disease prevalence across both anorexia nervosa and bulimia nervosa (1). Less is known about how these factors affect the development of disordered eating behaviors (DEB) among gender minorities—that is, individuals whose gender identities are discordant with their sex assigned at birth.This case report describes a transgender male patient with an extensive psychiatric history, who was admitted to the inpatient psychiatric unit for a suicide attempt and was found during this admission to have atypical anorexia nervosa. The purpose of this case report is to explore the ways in which the psychopathology underlying DEB and eating disorders can differ between transgender and cisgender individuals.Case PresentationA 19-year-old female-to-male (FtM) transgender patient with a psychiatric history of attention-deficit hyperactivity disorder (ADHD), bipolar I disorder, and borderline personality disorder presented to the emergency department because of a suicide attempt. The patient reported increasing depressive symptoms, including poor appetite, in the weeks leading up to this admission. On arriving in the inpatient psychiatric unit, the patient disclosed that he had not eaten food since the day prior to admission. The patient stated that he did “not have a good relationship with food” and restricted his caloric intake in an attempt to alter his body shape. His food restriction behaviors included limiting his daily intake to 500 to 1,000 kilocalories. His purging behaviors included self-induced vomiting after meals, ranging from twice a day to once every 2 weeks. The patient endorsed a history of excessive exercise and denied current binging behaviors. His body mass index was 26 at the time of admission.At age 8, the patient first received psychiatric care for ADHD. At age 11, he was diagnosed as having depression, with nonsuicidal, self-injurious behaviors (e.g., cutting and burning). At age 12, the patient began to identify as male. Family members were not supportive of the patient’s gender identity and continued to misgender the patient, which the patient felt contributed to the worsening of his depression. Subsequently, the patient began to engage in the restriction of his caloric intake, self-induced emesis, and excessive exercise to halt the development of secondary female characteristics during puberty. Throughout his adolescence, the patient continued to engage in DEB to “feel a sense of control” and “lose weight.” Worsening depressive symptoms led to two suicide attempts and a psychotic break at age 18.DiscussionEating disorders more commonly affect cisgender women than cisgender men; however, less is known about how gender minorities are affected. One literature review identified 20 publications between 2014 and 2019 on eating disorder diagnoses and symptoms among transgender youths, 10 of which were case studies (3). The existing case studies depicted a theme of gender dysphoria leading to DEB, especially food restriction as a means of delaying the progression of puberty (3). The patient described in this case study began to identify as male and displayed DEB around the onset of puberty at age 12.Puberty contributes to the development of eating disorders in cisgender females because of associated weight gain and redistribution of body fat (4). The changes in body shape can increase body image dissatisfaction and lead to DEB (4). These same changes in body shape and weight likely contribute to the development of DEB among patients who identify as transgender and nonbinary (TGNB). Additionally, the development of secondary sexual characteristics during puberty is particularly distressing to those who do not identify with their sex assigned at birth and can lead to attempts to delay or halt the progression of puberty (5). Diet restriction and excessive exercise are far more accessible than is gender-affirming care, especially for adolescents. Consequently, DEB can delay the onset of puberty, slow breast development, and cause amenorrhea; this may be particularly desirable for FtM transgender patients (5). Of note, the prevalence of eating disorders is higher among FtM patients than male-to-female (MtF) patients, which suggests that female sex may be an independent risk factor for DEB (6).When discussing the psychopathology of eating disorders and gender dysphoria, puberty needs to be considered a social factor as well as a biological factor. In Western cultures, societal expectations for thinness are prominent for female adolescents and contribute to the development of eating disorders (5). Such societal expectations of body weight and shape can be exacerbated for transgender patients (5, 6) because the development of secondary sexual characteristics makes it more difficult to conform to the expected appearance of their gender (7). The rate of suicidality is higher among transgender adolescents, and a contributing factor is the development of secondary sexual characteristics that are discordant with their gender identities (8). MtF transgender patients tend toward concerns of body weight and shape, concurrent with the eating disorder psychopathology associated with cisgender females (5, 7). On the other hand, DEB among FtM transgender patients may reflect a desire to change their bodies to better represent their gender identities. Examples of this include methods to halt the progression of puberty, as previously mentioned, as well as excessive exercise for muscle building in order to gain a more masculine appearance (5–7).Both eating disorders and gender dysphoria are characterized by high rates of body dissatisfaction; however, the reasons behind the dissatisfaction differ (9). In eating disorders, body dissatisfaction is rooted in the fear of weight gain and perceived body fat (1). In gender dysphoria, body dissatisfaction is often focused on secondary sex characteristics that are discordant with the individual’s gender identity. It is important to note that transgender individuals also have higher rates of dissatisfaction with body parts that are not sex specific, such as facial features and body shape (9). The increased risk of body dissatisfaction observed among transgender individuals can become a risk factor for DEB and eating disorders (9).Although biological, psychological, and social factors associated with puberty may increase the risk of gender dysphoria and DEB among transgender individuals, this may not be apparent to patients (9). An additional sociocultural factor that could contribute to the development of an eating disorder in TGNB patients is minority stress. Minority stress theory claims that TGNB individuals experience a higher prevalence of mental health issues because of social stigma, violence, and rejection related to their gender identity (10). Thus “DEB can serve as a coping mechanism in response to a greater burden of stress rather than strictly as a response driven by gender dysphoria alone” (11). The family of the patient described in this report did not accept his gender identity, which was distressing to him. Gender-related nonaffirmation is a contributing factor to minority stress and poor mental health outcomes (12). Additionally, transgender individuals who use DEB as a coping mechanism could change their appearance, albeit unintentionally. Changes in appearance could result in the individual being perceived and treated differently by society, which could lessen the person’s minority stress burden and serve to reinforce DEB.Among cisgender female patients, the social pressure of body image ideals and physiologic changes associated with puberty are often seen as factors contributing to the development of eating disorders. This case report brings attention to some of the ways in which these factors can contribute to the development of DEB and eating disorders among TGNB patients. Body dissatisfaction among TGNB patients can be exacerbated by the development of secondary sex characteristics during puberty. For youths wanting their appearance to reflect their gender identity, disordered eating serves as an easily accessible method to alter one’s body shape. Further studies are needed to validate diagnostic tools for eating disorders among TGNB patients and investigate ways that the complexities of gender identity can be integrated into the treatment of such patients.Key Points/Clinical PearlsBody dissatisfaction is characteristic of gender dysphoria and can contribute to the development of an eating disorder.Both eating disorders and gender dysphoria tend to begin during adolescence, with puberty as a possible precipitating factor.The psychopathology underlying eating disorders may differ in gender-diverse patients, compared with cisgender female patients.Transgender patients can use disordered eating behavior as a coping mechanism, even when the behavior is not related to body image dissatisfaction.Emma Banasiak is a fourth-year medical student at Hackensack Meridian School of Medicine, Nutley, N.J.The author has confirmed that details of the case have been disguised to protect patient privacy.

Clinical and Radiological Outcomes of Revision Total Hip Arthroplasty for Patients with Prior Hartofilakidis Type C Hip Dysplasia.

ObjectiveTo investigate the clinical and radiological results of revision total hip arthroplasty (THA) for patients with previously diagnosed Hartofilakidis type C hip dysplasia, which is technically challenging and lacks literature.MethodsWe enrolled 20 patients with previously diagnosed Hartofilakidis type C hip dysplasia who underwent revision THA between November 2008 and July 2015 at our hospital. Patients were followed up for an average of 87 months. Data pertaining to the Harris hip score (HHS), modified Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), general satisfaction, and the level of satisfaction related to 16 hip functions or issues experienced after revision THA were collected. The vertical and horizontal center of rotation (COR) of the hips were measured bilaterally based on preoperative and postoperative anteroposterior radiographs. Categorical variables were analyzed by the chi‐square test. Continuous variables were analyzed using the student's t test or non‐parametric Wilcoxon Rank Sum test.ResultsThere were significant postoperative improvements in the HHS (47.4 ± 31.6 vs 70.1 ± 39.0), modified WOMAC (48.5 ± 27.9 vs 75.7 ± 36.8), and the vertical (45.7 ± 33.7 mm vs 21.6 ± 21.8 mm) and horizontal (41.8 ± 17.0 mm vs 31.4 ± 14.7 mm) offset of the COR after revision THA (P < 0.05). Fifteen (75.0%) patients were satisfied with the procedure. The satisfaction rate for each of the 16 items ranged from 45% to 100%. The top three dissatisfactory items were squatting, getting into/out of cars, and leg‐length discrepancy. Postoperatively, dissatisfied patients had a significantly higher visual analogue scale pain score and lower WOMAC pain, HHS pain, WOMAC total, and HHS total scores, a lower satisfaction rate for pain relief, and a higher vertical COR.ConclusionThere is a high rate (25%) of dissatisfaction with the outcome after revision THA for patients with prior Hartofilakidis type C hip dysplasia. The most likely reasons for dissatisfaction were inadequate pain relief and a higher vertical COR measured on radiography.

A practical technique of reverse orbicularis oculi muscle resection with preserved subcutaneous capillary network for double eyelid blepharoplasty

BackgroundTraditional full-incision double eyelid blepharoplasty has several significant disadvantages, including slow recovery and bilateral asymmetry, which results in high rates of patient dissatisfaction. These problems can be minimized using improved surgical techniques aimed at reducing tissue damage and bleeding, decreasing operation time, and especially at protecting the subcutaneous capillary network during the operation. We therefore aimed to guard the capillary network and reduce intraoperative bleeding using the practical technique of reverse orbicularis oculi muscle resection. MethodsFifty cases of double eyelid blepharoplasty with traditional full-incision (group A) and 61 cases of reverse double eyelid blepharoplasty with a preserved capillary network (group B) were divided into two groups from October 1 to December 31, 2021 and from March 1 to May 31, 2022, respectively. The orbicularis oculi muscle was removed reversely from the front of the tarsal plate using double eyelid blepharoplasty, and the muscular membrane and subcutaneous capillary network were preserved. The operation time recorded in previous medical records was checked and compared with that of our novel technique. The recovery of double eyelid blepharoplasty was determined at 1, 4, and 12 weeks after the operation and patient satisfaction was also compared with that in previous medical records of patients in group A. ResultsThe reverse double eyelid blepharoplasty procedure was less complicated and easier to control than the traditional full-incision double eyelid blepharoplasty methodology. The average operation time of the double eyelid blepharoplasty cases with traditional full-incision was significantly greater than that of the cases of reverse double eyelid blepharoplasty with the capillary network preserved (45.68 ​± ​5.27 ​min and 31.11 ​± ​5.58 ​min, respectively; t=14.018 9, P=0.000 0). Patient satisfaction was 42% and 78.69%, respectively, at 1 week post-operation (χ2=15.724 8, P=0.000 1), 62% and 90.16% at 4 weeks post-operation (χ2=12.490 2, P=0.000 4), and 90% and 95.08%, at 12 weeks post-operation (χ2=1.061 1, P=0.303 0). ConclusionReverse double eyelid blepharoplasty with preserved subcutaneous capillary network effectively decreases the operation time and improves post-operative patient satisfaction. It is a double eyelid blepharoplasty method worthy of popularization.

The Prevalence and Predictors of Patient Dissatisfaction 5-years Following Primary Total Knee Arthroplasty.

Previous studies have evaluated patient dissatisfaction after total knee arthroplasty (TKA) at 1 year, but there is no data about the prevalence of dissatisfaction among TKA patients after prolonged follow-up. The purpose of this study is to determine patient dissatisfaction 5-years after TKA and to identify patient factors predictive of dissatisfaction. Demographic and clinical data on 4402 patients undergoing primary unilateral TKA between 2012 and 2015 were collected prospectively through the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR) comparative effectiveness consortium including diverse community and academic practices distributed across 23 states in the United States. Data collected at 1 year preoperatively and 5 years postoperatively included patient satisfaction (using a 5-point Likert satisfaction scale) and patient-reported outcome measures (PROMs) including the Knee injury and Osteoarthritis Outcome Score (KOOS) and Short-Form health survey (36-item). A univariate analysis of the difference between the satisfied and dissatisfied patients' groups was performed. A multivariate logistic regression model with 95% confidence interval (CI) was used to identify independent predictors of dissatisfaction at 5 years. The regression model was performed after adjusting the following variables: age, gender, body mass index (BMI), Charlson Comorbidity Index (CCI), marital status, smoking, education, and insurance type. The Receiver Operating Characteristic (ROC) analysis was performed with the measurement of area under curve (AUC). Hosmer-Lemeshow goodness of fit test was performed to evaluate the validity of the model. A total of 12.7% patients (559/4402) reported dissatisfaction 5-years after TKA. Increased BMI, higher CCI, higher Oswestry disability index, and increased number of other painful lower extremities (LE) joints were significantly associated with dissatisfaction. Higher rates of dissatisfaction were present in young patients, patients with less education, and non-White patients. Patient dissatisfaction was significantly associated with poor preoperative and 5-year postoperative PROMs scores and less score improvement from baseline to 5 years (P < .001). The multivariate regression analysis showed that an increased number of other painful LE joints (OR= 1.81; 95% CI (1.14-2.88) (P= .01), increased Oswestry back disability index (OR= 1.40; 95% CI (1.07-1.82) (P= .01), non-White patients (OR= 1.74; 95% CI (1.26-2.40) (P= .001), and minimal preoperative functional disability with KOOS function in daily living (ADL) score ≥70 (OR= 0.64; 95% CI (0.43-0.95) (P= .02) were independent predictive factors for dissatisfaction at 5 years. A total of 12.7% patients reported dissatisfaction 5-years after TKA. Clinical profiles of the satisfied and dissatisfied patients were captured 5-years after TKA with differences in the preoperative demographic and clinical characteristic variables identified. Risk factors for long-term patient dissatisfaction after TKA have been identified and should be considered during shared decision making while planning for TKA. Surgeons should use these identified risk factors to set realistic expectations for patients at an increased risk for dissatisfaction aiming to optimize their outcomes and increase their long-term satisfaction after TKA.

Nonoperative treatment of acromial fractures following reverse shoulder arthroplasty: clinical and radiographic outcomes.

Acromion/scapular spine fractures (ASFs) remain a challenging complication following reverse shoulder arthroplasty (RSA). Historically, nonoperative management has been the treatment of choice, with variable results. The purpose of this study is to report on both clinical and radiographic outcomes of nonoperative treatment. A new subclassification of Levy type II acromion fractures will be proposed, and outcomes will be evaluated in relation to the modified Levy classification. Forty-four patients diagnosed with ASF following RSA were matched 1:3 to a control group based on gender, age, and preoperative function. All ASF patients were treated nonoperatively. Patient-reported outcome measures, consisting of American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Simple Shoulder Test, Single Assessment Numerical Evaluation, visual analog scale pain and function scores, satisfaction, and active range of motion were gathered preoperatively and at the most recent follow-up. Outcomes were stratified based on fracture type. Radiographic findings including fracture union, scapular rotation, progressive notching, and osteolysis were reviewed from latest follow-up and compared with initial postoperative films. ASFs were identified at a median of 2 months following RSA (8 type I; 22 type II; 14 type III), followed for a median of 37 months and compared to 108 matched controls. Patients with ASF had inferior clinical outcomes with a higher rate of dissatisfaction (27.8%) when compared to controls. Lateral fracture subtypes (I and IIA) were similar to controls and had little impact on outcomes. However, medial fracture subtypes (type IIB, IIC, and III) demonstrated inferior outcomes when compared to controls, with type III fracture patients demonstrating no improvement from baseline. The overall nonunion rate was 61.4%, with high rates of scapular rotation and osteolysis in medial fracture subtypes. Nonunion was associated with a higher incidence of secondary radiographic findings, including scapular rotation, progressive notching, and osteolysis. Results of nonoperative treatment of ASF following RSA differs based on fracture location. Fractures that occur at or medial to the glenoid face (IIB, IIC, III) demonstrate high rates of unsatisfactory results and worse clinical outcomes. Concerning radiographic findings of scapular tilt, progressive scapular notching and osteolysis were seen at a higher rate with medial fracture types and fracture nonunions.

Commentary on “Remote Advance Care Planning in the Emergency Department During COVID-19 Disaster: Program Development and Initial Evaluation”

Novel applications of telehealth exploded during the pandemic.1Hollander J.E. Carr B.G. Virtually perfect? Telemedicine for Covid-19.N Engl J Med. 2020; 382: 1679-1681https://doi.org/10.1056/NEJMp2003539Crossref PubMed Scopus (1441) Google Scholar From virtual acute care visits to virtual triage and home visits and telehealth via ambulances, synchronous and asynchronous telehealth etched a permanent place in the emergency care specialty.2Pierce B.S. Perrin P.B. Dow A.W. Dautovich N.D. Rybarczyk B.D. Mishra V.K. Changes in physician telemedicine use during COVID-19: effects of practice setting, demographics, training, and organizational policies.Int J Environ Res Public Health. 2021; 18: 9963https://doi.org/10.3390/ijerph18199963Crossref PubMed Scopus (1) Google Scholar In this edition of the Journal of Emergency Nursing (JEN), Liberman et al3Liberman T. Roofeh R. Chin J. et al.Remote advanced care planning the emergency department during COVID-19 disaster: program development and initial evaluation.J Emerg Nurs. 2022; 48 (https://doi.org/10.1016/j.jen.2021.09.006): 22-31Abstract Full Text Full Text PDF Scopus (1) Google Scholar explore a pragmatic telehealth program developed to take the heavy, bedside end-of-life discussion away from the front-line staff and offload it to a trained group of nurses via telehealth. A logic model describing the use of Remote Goals of Care Program (GOC) was developed and implemented. The emergency department can be loud and crowded and lack the quiet privacy needed to have end-of-life discussions with patients and families. During the COVID-19 pandemic, when visitation policies were restricted, many end-of-life discussions took place via remote platforms.4Selman L.E. Sowden R. Borgstrom E. ‘Saying goodbye’ during the COVID-19 pandemic: a document analysis of online newspapers with implications for end of life care.Palliat Med. 2021; 35: 1277-1287https://doi.org/10.1177/02692163211017023Crossref PubMed Scopus (9) Google Scholar Patients were often scared, alone, and dying of COVID-19 without their closest loved ones to hold their hands at the bedside. Many hospitals had transitioned to a virtual platform to deliver bad news and work through these decisions; however, the authors’ GOC program3Liberman T. Roofeh R. Chin J. et al.Remote advanced care planning the emergency department during COVID-19 disaster: program development and initial evaluation.J Emerg Nurs. 2022; 48 (https://doi.org/10.1016/j.jen.2021.09.006): 22-31Abstract Full Text Full Text PDF Scopus (1) Google Scholar used a bidirectional platform. This was unique in that both the patient and the bedside clinician were remote. Telehealth programs in the emergency department such as remote stroke care and tele-psychiatry are examples of established one-directional programs—the patient is in person in the bricks-and-mortar emergency department, but the provider is remote. These programs spared the provider the exposure risks from being physically present during the visit during the pandemic. The programs that were bidirectional—both the patient/family and the provider were remote—included acute unscheduled visits and platforms that connected families to remote providers. Pairing both the need for virtual conversations and job continuity for nurses sidelined during the pandemic, this Remote GOC Program3Liberman T. Roofeh R. Chin J. et al.Remote advanced care planning the emergency department during COVID-19 disaster: program development and initial evaluation.J Emerg Nurs. 2022; 48 (https://doi.org/10.1016/j.jen.2021.09.006): 22-31Abstract Full Text Full Text PDF Scopus (1) Google Scholar offered a sustainable solution to a major gap in care. The program developed a system by which the bedside team could alert the remote palliative care providers to engage the family in end-of-life decisions.4Selman L.E. Sowden R. Borgstrom E. ‘Saying goodbye’ during the COVID-19 pandemic: a document analysis of online newspapers with implications for end of life care.Palliat Med. 2021; 35: 1277-1287https://doi.org/10.1177/02692163211017023Crossref PubMed Scopus (9) Google Scholar These included DNR/DNI, MOLST, health care proxy discussions, and disposition. The Remote GOC Program3Liberman T. Roofeh R. Chin J. et al.Remote advanced care planning the emergency department during COVID-19 disaster: program development and initial evaluation.J Emerg Nurs. 2022; 48 (https://doi.org/10.1016/j.jen.2021.09.006): 22-31Abstract Full Text Full Text PDF Scopus (1) Google Scholar was created as a joint endeavor between the division of geriatrics and palliative medicine and emergency medicine. “In decanting the responsibility of goals of care discussions from the emergency department to a calmer, remote setting,” the authors seized a unique moment in time, a time where the most precious conversations regarding end-of-life care could were transitioned to a group of nurses working remotely. While this was a nurse-driven initiative, it spanned disciplines including social work and the division of palliative care and emergency medicine, fueling the success of this program. The advantages of such a program include offloading the clinical team from having difficult, often prolonged discussions at the bedside. The nurses conducting the interviews were not on site, allowing protection from COVID-19 exposure and conservation of precious personal protective equipment (PPE).5Adams J.G. Walls R.M. Supporting the health care workforce during the COVID-19 global epidemic.JAMA. 2020; 323: 1439-1440https://doi.org/10.1001/jama.2020.3972Crossref PubMed Scopus (718) Google Scholar The pandemic created extraordinary emotional and physical stress on bedside care teams. Health care workers struggled to communicate with the patients in full PPE, screaming above the whirl of the PAPR hood and N95 masks. Face shields prevented not only droplets from spreading but words from traveling, and conversations were strained at best.6Boran M. Boran O.F. Korukcu O. Ozkaya M. The psychological resilience and perceived stress of the frontline heroes in the pandemic in Turkey: a descriptive study of the COVID-19 outbreak-mutations-normalization triad.Jpn J Nurs Sci. 2021; e12442https://doi.org/10.1111/jjns.12442Crossref PubMed Scopus (1) Google Scholar Caregivers of patients who were not capable of making end-of-life decisions for themselves attempted to connect to next of kin via iPad. The telehealth platform for end-of-life care was born. Considerations on supporting the entire health care workforce included providing work during quarantine, providing offsite work to those health care workers at higher risk of contracting severe COVID-19, and providing a channel to support both the emotional needs of the emergency health care workers at the bedside and the need to work for those sidelined; this program was ideal. The authors created a logic model for Remote GOC Program,3Liberman T. Roofeh R. Chin J. et al.Remote advanced care planning the emergency department during COVID-19 disaster: program development and initial evaluation.J Emerg Nurs. 2022; 48 (https://doi.org/10.1016/j.jen.2021.09.006): 22-31Abstract Full Text Full Text PDF Scopus (1) Google Scholar for other institutions to replicate their implementation. The inputs included the key partnership between emergency medicine and palliative care, nurses who were not onsite, the technology to perform the telehealth visits. Outputs include number of referrals into the program, GOC discussions with families, and any changes in code status. Evidence of the anticipated impact of this program after the pandemic will be continued offloading of the cognitive burden of the bedside clinician and providing meaningful work for nurses sidelined from clinical practice. The pitfalls of this type of program are typical of many telehealth programs, with a few unique challenges. Families may not have access to the technology needed to conduct the telehealth interview. This lack of access is more prevalent in lower socioeconomic and rural areas.7Schoen JC, Russi CS, Laack TA. Addressing barriers to telemedicine use in rural emergency medicine: leveraging in situ simulation. Telemed JE Health. Published online April 19, 2021. https://doi.org/10.1089/tmj.2021.0026Google Scholar These types of technology barriers may be more profound during a very intense end-of-life discussion compared with a virtual visit for an uncomplicated self-limited medical condition. Glitches in Wi-Fi or software may be extremely intrusive in these sensitive moments. There may also be conflicting advice given to the patient’s family by a telehealth nurse who is not the patient’s primary in-person bedside nurse. Would the weight given to the information provided to make such difficult decisions be watered down by the nurse being remote? There is something profound about the bedside clinician giving advice regarding advanced directives with the patient in front of them. Would a virtual approach convey the same meaning? Health care providers, including nurses, are often sidelined from clinical care secondary to injury, illness, exposure, or, recently, COVID-19 quarantine.8Fowler S.B. Rosado C.A. Jones J. Ashworth S. Adams D. Novel use of a nurse-led telemedicine team in acute stroke: a retrospective review of the impact on a regional health care system.J Emerg Nurs. 2019; 45: 242-248https://doi.org/10.1016/j.jen.2018.07.026Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar This unique GOC program3Liberman T. Roofeh R. Chin J. et al.Remote advanced care planning the emergency department during COVID-19 disaster: program development and initial evaluation.J Emerg Nurs. 2022; 48 (https://doi.org/10.1016/j.jen.2021.09.006): 22-31Abstract Full Text Full Text PDF Scopus (1) Google Scholar paired the nurses who were not able to work clinically to participate in a valuable program. The use of nursing in telehealth has expanded rapidly over the past 5 years. A gap still exists around telenursing and disaster care. This application of telehealth as an avenue for emergency nurses to use their specialized skillsets begins to fill this gap. The telehealth platform for nursing seemed counterintuitive at first, with the goals of bedside nursing to be truly a hands on specialty. There was a delayed launch of the specific telehealth nursing applications.8Fowler S.B. Rosado C.A. Jones J. Ashworth S. Adams D. Novel use of a nurse-led telemedicine team in acute stroke: a retrospective review of the impact on a regional health care system.J Emerg Nurs. 2019; 45: 242-248https://doi.org/10.1016/j.jen.2018.07.026Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar The potential for delivering nursing care such as patient history, triage, individualized patient education, postdischarge counseling, and care coordination is enormous. Nurse-led telehealth initiatives during the pandemic provided a platform for virtual care that limited infection exposures and physical demands and allowed flexibility to work from home. The pandemic disproportionately affected working parents, who had to manage their jobs, their own psychological stressors, and children who were learning at home during lockdown. The use of telehealth to mitigate the occupational psycho-social stressors during the pandemic can be stretched to postpandemic times.9Delaney R.K. Locke A. Pershing M.L. et al.Experiences of a health system’s faculty, staff, and trainees’ career development, work culture, and childcare needs during the COVID-19 pandemic.JAMA Netw Open. 2021; 4e213997https://doi.org/10.1001/jamanetworkopen.2021.3997Crossref PubMed Scopus (14) Google Scholar Health care is not only complicated, it has now become draining, leading to high rates of burnout and dissatisfaction. Allowing nurses to intermittently perform their duties from home is one possible solution, for some nurses, some of the time.10Castner J. Bell S.A. Hetland B. Der-Martirosian C. Castner M. Joshi A.U. National estimates of workplace telehealth use among emergency nurses and all registered nurses in the United States.J Emerg Nurs. 2022; 48 (https://doi.org/10.1016/j.jen.2021.07.001): 45-56Abstract Full Text Full Text PDF Scopus (1) Google Scholar The Remote GOC Program3Liberman T. Roofeh R. Chin J. et al.Remote advanced care planning the emergency department during COVID-19 disaster: program development and initial evaluation.J Emerg Nurs. 2022; 48 (https://doi.org/10.1016/j.jen.2021.09.006): 22-31Abstract Full Text Full Text PDF Scopus (1) Google Scholar manuscript provides important feasibility evidence that remotely working nurses can engage patients in end-of-life discussions. During staff shortages, remote nurses can potentially help perform the admission intake for patients boarding the emergency department; they may be able to provide more continuous visual monitoring or patient surveillance care when staffing levels cannot be maintained. Remote nurses might be engaged to have more comprehensive discharge planning meetings with patients and their families. The pandemic taught us that you can be an emergency nurse but do not need to be in an emergency department to deliver specialty care. It is about the skill set and not the location. The paper by Liberman et al3Liberman T. Roofeh R. Chin J. et al.Remote advanced care planning the emergency department during COVID-19 disaster: program development and initial evaluation.J Emerg Nurs. 2022; 48 (https://doi.org/10.1016/j.jen.2021.09.006): 22-31Abstract Full Text Full Text PDF Scopus (1) Google Scholar illustrates that very nicely. Through their discussion about end of life, they have breathed new life into how we care for patients. Jennifer Lynn White is Director of Clinical Operations - TJUH Emergency Department, Clinical Associate Professor, Department of Emergency Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA. Twitter: @jlynnwhite4 . Judd E. Hollander is Senior Vice President of Healthcare Delivery Innovation at Thomas Jefferson University, Philadelphia, PA; and Associate Dean for Strategic Health Initiatives at Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA.