IMPORTANCE Delaying critical care for treatable conditions owing to fear of contracting in the emergency department (ED) is associated with avoidable morbidity and mortality. OBJECTIVE To assess and quantify how people decided whether to present to the ED during the COVID-19 pandemic for care unrelated to COVID-19 using conjoint analysis, a form of trade-off analysis that examines how individuals make complex decisions. DESIGN, SETTING, AND PARTICIPANTSThis cross-sectional survey study was conducted using a nationwide sample from June 1, 2020, during the initial peak of the COVID-19 pandemic. Included participants were adults aged 18 years or older in the US who self-reported that they had not tested positive for COVID-19. Data were analyzed from July 2020 through May 2021.EXPOSURES Participants completed a self-administered online survey. MAIN OUTCOMES AND MEASURESUsing a choice-based conjoint analysis survey, the relative importance was assessed for the following attributes for individuals in deciding whether to seek ED care for symptoms consistent with myocardial infarction or appendicitis: reduction in chance of dying because of ED treatment, crowdedness of ED with other patients, and chance of contracting COVID-19 in the ED. We also performed latent class analyses using conjoint data to identify distinct segments of the respondent population with similar choice patterns. Logistic regression was then used to explore whether patient sociodemographics and political affiliations were factors associated with decision-making. RESULTS Among 1981 individuals invited to participate, 933 respondents (47.1%) completed the survey; participants' mean (SD) age was 40.1 (13.0) years, and 491 (52.6%) were women. In latent class analyses, 158 individuals (16.9%) with symptoms of myocardial infarction and 238 individuals (25.5%) with symptoms of appendicitis prioritized avoidance of COVID-19 exposure in the ED (ie, chance of contracting COVID-19 in the ED or crowdedness of ED with other patients) over seeking appropriate care for symptoms. Having a usual source of care was a factor associated with lower odds of prioritizing avoidance of COVID-19 exposure (myocardial infarction scenario: adjusted odds ratio, 0.49 [95% CI, 0.32-0.76]; P = .001; appendicitis scenario: adjusted odds ratio, 0.57 [95% CI, 0.40-0.82]; P = .003), but most sociodemographic factors and political affiliations were not factors associated with decision-making. CONCLUSIONS AND RELEVANCEThis study found that up to one-quarter of individuals were willing to forgo potentially life-saving ED care to avoid exposure to COVID-19. These findings suggest that health care systems and public health organizations should develop effective communications (continued)
Background: Calcaneoplasty is a common procedure performed for the management of Haglund’s syndrome when nonoperative management fails. Midline tendon-splitting and endoscopy are 2 common approaches to calcaneoplasty. Studies have suggested that an endoscopic approach may allow earlier return to activity and superior outcomes, but there are no biomechanical or clinical studies to validate these claims. The goal of this study was to quantify and compare Achilles tendon pullout strength following midline tendon-splitting and endoscopic calcaneoplasty in cadaveric specimens. Methods: Twelve match-paired cadaveric specimens were randomly divided into 2 groups: endoscopic and midline tendon-split. Following calcaneoplasty, fluoroscopy was used to match bone resection and the Achilles was loaded to failure in a mechanical testing system. A paired-samples t test was conducted to compare bone resection height, bone resection angle, load to failure, and mode of failure. Results: The endoscopic approach yielded a 204% greater postsurgical pullout strength for the Achilles tendon than the midline tendon-split (1368 ± 370 N vs 450 ± 192 N, respectively) ( P < .05). There were no differences in resection angle or resection height. All specimens failed due to bone or tendon avulsion. Conclusion: Endoscopic calcaneoplasty had more than 3 times greater pullout strength than the midline tendon-splitting approach. Clinical Relevance: This may allow earlier return to functional rehabilitation following endoscopic calcaneoplasty, but further studies are needed to determine if these differences are clinically significant. Further understanding of the time-zero biomechanics following calcaneoplasty may provide guidance regarding postoperative management with respect to surgical approach.
Replacement of lost cranial bone (partly mesodermal and partly neural crest‐derived) is challenging and includes the use of nonviable allografts. To revitalize allografts, bone marrow‐derived mesenchymal stromal cells (mesoderm‐derived BM‐MSCs) have been used with limited success. We hypothesize that coating of allografts with induced neural crest cell‐mesenchymal progenitor cells (iNCC‐MPCs) improves implant‐to‐bone integration in mouse cranial defects. Human induced pluripotent stem cells were reprogramed from dermal fibroblasts, differentiated to iNCCs and then to iNCC‐MPCs. BM‐MSCs were used as reference. Cells were labeled with luciferase (Luc2) and characterized for MSC consensus markers expression, differentiation, and risk of cellular transformation. A calvarial defect was created in non‐obese diabetic/severe combined immunodeficiency (NOD/SCID) mice and allografts were implanted, with or without cell coating. Bioluminescence imaging (BLI), microcomputed tomography (μCT), histology, immunofluorescence, and biomechanical tests were performed. Characterization of iNCC‐MPC‐Luc2 vs BM‐MSC‐Luc2 showed no difference in MSC markers expression and differentiation in vitro. In vivo, BLI indicated survival of both cell types for at least 8 weeks. At week 8, μCT analysis showed enhanced structural parameters in the iNCC‐MPC‐Luc2 group and increased bone volume in the BM‐MSC‐Luc2 group compared to controls. Histology demonstrated improved integration of iNCC‐MPC‐Luc2 allografts compared to BM‐MSC‐Luc2 group and controls. Human osteocalcin and collagen type 1 were detected at the allograft‐host interphase in cell‐seeded groups. The iNCC‐MPC‐Luc2 group also demonstrated improved biomechanical properties compared to BM‐MSC‐Luc2 implants and cell‐free controls. Our results show an improved integration of iNCC‐MPC‐Luc2‐coated allografts compared to BM‐MSC‐Luc2 and controls, suggesting the use of iNCC‐MPCs as potential cell source for cranial bone repair.
Category: Hindfoot Introduction/Purpose: The risk of Achilles avulsion is the limiting factor in return to full weight bearing and early activity following calcaneoplasty for Haglund’s syndrome. The most commonly performed surgical procedure is an open calcaneoplasty through a posterior approach. Another option is an endoscopic decompression, which theoretically causes less disruption of the Achilles insertion, and allows a more rapid return to full weight bearing and activity. Despite this potential benefit no study has assessed the difference in Achilles tendon pull-out strength after open versus endoscopic techniques. The purpose of this study was to investigate those changes in a cadaveric model and provide objective data upon which to base postoperative recovery. Methods: Six matched pairs of cadaveric specimens(mid-tibia to toes) were randomly divided into two surgical groups.Group#1 was treated with an endoscopic decompression under fluoroscopic guidance using a 4 mm burr.Group#2 was treated with a traditional calcaneoplasty through a posterior approach using a microsaggital saw.The Achilles was repaired back to the calcaneus with two nonsabsorbable suture anchors in Group #2.Fouroscopic guidance was used to exactly match the amount of bone removed from each matched pair.Pre and post procedure true lateral x-rays were obtained in both groups to quantify bone loss.These radiographic images were imported into Matlab computational software(MathWorks, Inc., Natick, MA) for digital analysis. The distal aspect of each calcaneus was potted and held at a 20 degree angle.The Achilles tendon was secured in a freeze-clamp, which was attached to a mechanical testing system. Specimens were then loaded to failure. Outcome measures include: Height of bony resection, angle of bone resection and load to failure. Results: To date our results show significantly higher pullout forces in specimens that had an endoscopic calcaneoplasty (average failure load: 1368 ±445 N) compared to those that received an open surgical procedure (450±184 N), p<0.05. On average, the endoscopic technique had a 204% greater pull out strength compared to the open cohort. The calcaneal resection angle (37 degrees vs 39 degrees, p=.6) and the height of bony resection (49% vs 51%, p=.39) were not statistically significant between the open and endoscopic techniques. Conclusion: This study describes the first biomechanical comparison of Achilles pull-out-strength between open and endoscopic calcaneoplasty.The endoscopic-technique had 204%greater pull-out-strength compared to the open-technique.Even though equal amounts of bone were resected in each technique, the open-technique requires more disruption of the Achilles insertion to accommodate the saw.This marked difference in pull-out-strength demonstrates the vulnerability of the Achilles insertion following open treatment.Our results support protected weight-bearing and cautious return to activity following open surgery. Also an endoscopic-technique results in significantly increased post-sur...
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