Integrating digital scholarship in dental education: Why, what, and how?

The aim of this perspective paper is to highlight the potential role and value digital scholarship can have in dental education. The use of digital scholarship and alternative metrics for academic assessment, promotion, and tenure is growing rapidly among healthcare scholars and can complement traditional frameworks. The US dental academic institutions might consider expanding the scope of their promotion and tenure guidelines from reliance on publications and grants to a greater appreciation of the impact of the scholar's work in the digital sphere by integrating newer citation indices and altmetrics.

A Long-Term Follow-Up Study of Former Dental School Teaching Assistants: Are They Teaching After Graduation?

There has been growth in teaching opportunities for dental students over the past two decades, but little research on whether these experiences have led to actual positions in academia. The aims of this study were to determine whether former teaching assistants at New York University College of Dentistry continued in dental academia after graduation or intended to teach during their careers and to assess their reasons for or for not teaching. Of the 294 former teaching assistants who taught their peers from 2003 to 2014, 106 responded to a survey, for a response rate of 36%. Of the respondents, 28% reported having teaching appointments, with 7% (n=8) having full-time teaching appointments and 21% (n=22) having part-time teaching appointments in a dental school or hospital-based program at some point after graduation. The most common reasons given for teaching were "intellectual stimulation" and "enjoyment" followed by "interactions with students." The most reported reason for not teaching was "student loan debt," followed by "too busy building private practice," "limited teaching opportunities in area," and "family commitments." Significantly, 95% of these former teaching assistants either taught or intended to teach during their careers, and they were six times less likely to rule out future teaching than dental school seniors in national surveys. These findings suggest that participating in teaching opportunities in dental school plants the seed for future teaching. More follow-up studies should be undertaken to see which types of teaching assistant programs are more successful in creating long-term teaching commitments.

Laboratory assessment of the quality of adult and neonatal red cell concentrates manufactured from whole blood, exchange transfusion or intrauterine transfusion red cell units

BACKGROUND

We evaluated the quality of red cell components in additive solution over 42 days of storage when re-manufactured from neonatal exchange transfusion (ExTx) or intrauterine transfusion (IUT) units on day 7 for issue to adults, neonates or infants.

MATERIALS AND METHODS

Red cell concentrates (RCC) manufactured from WB were compared to RCC re-manufactured from ExTx or IUT on day 7, and red cell splits (RCS) manufactured from WB were compared to RCS re-manufactured from ExTx or IUT on day 7. All components were stored at 2-6°C and tested throughout storage until day 42 for in vitro parameters of red cell quality. One RCS manufactured from each of WB, ExTx or IUT, was irradiated on day 14 and tested on day 28 along with a non-irradiated RCS from the same unit.

RESULTS

All the re-manufactured arms had no worse haemolysis, red cell microvesicle (RCMV) release or ATP over storage compared to controls. All arms complied with the 0·8% haemolysis UK specification, except for re-manufactured RCS from the IUT arm irradiated on day 14 and tested on day 28. Re-manufactured units had significantly decreased potassium levels compared to control over storage (P < 0·001 all).

CONCLUSION

RCC or RCS re-manufactured from ExTx or IUT units on day 7 are suitable for transfusion up to the standard day 35 of storage. Re-manufactured RCS from ExTx units (but not IUT), may be irradiated up to day 14 and stored for 14 days post-irradiation.

Characteristics of Effective Simulation (Preclinical) Teachers as Identified by Dental Students: A Qualitative Study

The aim of this qualitative research study was to identify and categorize criteria for simulation teacher quality preferences as reported by dental students. Second-year dental students at New York University College of Dentistry in 2015 were given a two-question, open-ended survey asking what qualities they liked most and least in a simulation or preclinical teacher. Responses were collected until data saturation was reached. Key words in the responses were identified and coded based on similar relationships and then were grouped into defined categories. A total of 168 respondents out of the target group of 363 students (46.3%) provided 1,062 written comments. Three core themes-character, competence, and communication-emerged from 16 defined categories, which were validated using references from the educational literature. The theme of character encompassed eight of the defined categories (motivation, available, caring, patience, professionalism, empathy, fairness, and happiness) and accounted for 50% of the total student responses. The theme of competence comprised five categories (expertise, knowledgeable, efficient, skillful, and effective) and represented 34% of all responses. The communication theme covered the remaining three categories (feedback, approachable, and interpersonal communication) and contained 17% of the responses. Positive and negative comments in the category of motivation accounted for 11.2% of all student responses. Expertise was the next highest category with 9.3% of the responses, followed closely by 9.1% in the category of available. Among these students, the top five attributes of simulation teachers were motivation, expertise, available, caring, and feedback. While the study did not attempt to correlate these findings with improved student performance, the results can be used in the development of assessment tools for faculty and targeted faculty development programs.

Dental Student Study Strategies: Are Self-Testing and Scheduling Related to Academic Performance?

Self-testing, a strategy wherein a student actively engages in creating questions and answers from study materials to assist with studying, has been found to be especially advantageous because it enhances future retrieval of information. Studies have found correlations among students' grade point averages (GPAs), self-testing, and rereading study strategies, as well as the spacing of study sessions over time. The aim of this study was to assess relationships among dental students' study strategies, scheduling of study time, and academic achievement. A 16-item survey requesting information on study habits, study schedules, and GPAs was distributed to 358 second-year dental students at New York University College of Dentistry. Additionally, the survey asked students to report the average number of hours per week they devoted to studying for didactic courses and preparing for hands-on preclinical courses. Of the 358 students, 94 (26%) responded to the survey. The vast majority of the respondents reported utilizing self-testing and rereading study strategies. High performers (with higher GPAs) were more likely to use self-testing, especially with flashcards, and to space their studying over multiple sessions. Lower performing students were more likely to highlight or underline their notes and to mass their study sessions or cram. Longer hours devoted to studying and practicing for simulation courses were associated with stronger performance; lower performers reported spending significantly fewer hours practicing for simulation courses. Half of the dental students surveyed said that they felt their studying would be more productive in the morning, although 84% reported doing most of their studying in the evening or late night. Sound study decisions depend on accurate regulation of ongoing learning and appropriate use and timing of evidence-based study strategies, so these results suggest that dental students may require guidance in these areas.

The Role of Organizational Context in the Creation and Sustainability of Dental Faculty Development Initiatives

Dental faculty development programs exist for a variety of reasons: to improve teaching skills, develop and reinforce relationships among colleagues and mentors, foster career development, and support curricular initiatives and institutional priorities. These activities impact individual faculty members as well as the institutions in which they work. Each institution has a distinct culture that should be acknowledged and understood alongside conventional outcome measures. As such, this article provides an expanded view of faculty development programming, associated educational activities, and related organizational changes at the College of Dentistry, New York University (NYU) since 2005. Contextual factors include the existence of an Office of Professional Development established in 1999, an Academy of Distinguished Educators founded in 2010, and other programs for present and future educators that support the college's educational mission. Outcomes include a comparison study of one program, the creation of new courses, the sustainability and expansion of existing programs, participants' retention rate, and an increase in awards and other educational accomplishments such as publication of abstracts, oral presentations, and related activities by NYU faculty at national forums in dental education.

Social Media in the Dental School Environment, Part A: Benefits, Challenges, and Recommendations for Use

Social media consist of powerful tools that impact not only communication but relationships among people, thus posing an inherent challenge to the traditional standards of who we are as dental educators and what we can expect of each other. This article examines how the world of social media has changed dental education. Its goal is to outline the complex issues that social media use presents for academic dental institutions and to examine these issues from personal, professional, and legal perspectives. After providing an update on social media, the article considers the advantages and risks associated with the use of social media at the interpersonal, professional, and institutional levels. Policies and legal issues of which academic dental institutions need to be aware from a compliance perspective are examined, along with considerations and resources needed to develop effective social media policies. The challenge facing dental educators is how to capitalize on the benefits that social media offer, while minimizing risks and complying with the various forms of legal constraint.

Social Media in the Dental School Environment, Part B: Curricular Considerations

The goal of this article is to describe the broad curricular constructs surrounding teaching and learning about social media in dental education. This analysis takes into account timing, development, and assessment of the knowledge, skills, attitudes, and behaviors needed to effectively use social media tools as a contemporary dentist. Three developmental stages in a student's path to becoming a competent professional are described: from undergraduate to dental student, from the classroom and preclinical simulation laboratory to the clinical setting, and from dental student to licensed practitioner. Considerations for developing the dental curriculum and suggestions for effective instruction at each stage are offered. In all three stages in the future dentist's evolution, faculty members need to educate students about appropriate professional uses of social media. Faculty members should provide instruction on the beneficial aspects of this communication medium and help students recognize the potential pitfalls associated with its use. The authors provide guidelines for customizing instruction to complement each stage of development, recognizing that careful timing is not only important for optimal learning but can prevent inappropriate use of social media as students are introduced to novel situations.

Do dental students use optimal study strategies?

Research on human learning has shown that repeated retrieval practice or self-testing maximizes learning. However, recent studies have found undergraduate students to be largely unaware of the benefits of self-testing. The aim of this study was to examine dental students' study strategies and utilization of retrieval techniques for learning. All second-year dental students at New York University College of Dentistry were invited to participate. Of the total 360 students, 66 completed the two-question survey, for a response rate of 18.3%. The first question asked students to choose from a list of twelve study strategies the ones they used and to rank their top five in order of personal preference. Repeated reading was the most frequently used strategy with 83.3% of students reporting that they used it and 43.9% naming it as their top strategy. Of these students, 45.5% indicated that they self-tested while studying, but none indicated it was their number one strategy. The second question asked students how they would study after reading a textbook chapter for the first time. They were asked to choose one option from three possibilities: going back and restudying, self-testing (with the possibility of restudying afterward), or some other strategy. On this question, 25.8% chose restudying, 45.5% chose self-testing, and 28.8% indicated they would use another study strategy. Thus, 54.6% of the students reported they would not test themselves after reading a textbook chapter. Of those who chose self-testing, only seven students indicated they would do so to improve learning. The results of this study suggest that the students lacked sufficient awareness of the superiority of self-testing for learning.

Effectiveness of an online tutorial on intimate partner violence for dental students: a pilot study

This pilot study sought to determine whether New York University College of Dentistry's online tutorial on domestic violence is effective for dental students poised to embark on their professional careers. The modular program is based on the RADAR model developed by the Massachusetts Medical Society. RADAR stands for Routinely screen, Ask direct questions, Document findings, Assess patient safety, and Review options and refer as indicated. An objective and validated measure, the Physician Readiness to Manage Intimate Partner Violence Survey (PREMIS), was given pre- and post-tutorial to determine whether it impacted senior dental students' knowledge, attitudes, beliefs, and behaviors about intimate partner violence. Study participants were twenty-five senior dental students (7 percent of a class of 358) who had not received didactic instruction in domestic violence for over two years. A quasi-experimental research design was utilized. Data analysis indicated statistically significant improvements in composite scale scores on the PREMIS Perceived Preparation, Perceived Knowledge, and Actual Knowledge sections. There was a statistically significant improvement on the self-efficacy and constraint opinion scales. The other six opinion scale scores showed improved but not statistically significant scores. This online tutorial was found to be effective in increasing the participants' perceived preparation, knowledge, and self-efficacy and decreasing perceptions of provider constraints in managing victims of intimate partner violence.

Long-term follow-up of a dental faculty development program

Many, if not most, dental faculty members have not received formal training to be educators. However, the importance of faculty development programs in improving teaching skills, fostering career development, and reinforcing relationships with colleagues and mentors has increasingly been acknowledged. In 2005, the Excellence in Clinical Teaching Program at New York University College of Dentistry (NYUCD) was created to enhance the clinical teaching skills of NYUCD faculty members. As of spring 2009, fifty-nine faculty members had participated in eight separate cohorts. The program consists of five formal group sessions supplemented by readings, reflection papers, and a final project. This study examined the short- and long-term effectiveness of the program. Participants were asked to complete a short pre-program survey to self-assess their teaching abilities and, at the last session, a satisfaction survey. In fall 2011, forty-eight faculty members who completed the program from spring 2005 to fall 2009 and were actively teaching at least one session a week at NYUCD were asked to complete a follow-up survey asking about the long-term value of the program and their academic career progression since program completion. Thirty-three faculty members responded for a response rate of 69 percent. Ninety-seven percent of the respondents indicated they would recommend the program to their colleagues, 94 percent said program participation led to a greater likelihood of conferring with peers about teaching issues,79 percent had increased their teaching responsibilities, and 62 percent said that presenting the final project improved their presentation skills. In addition, the retention rate of those still teaching at the school (81 percent) exceeds national retention rate averages for dental faculty. This follow-up study suggests that participation in the Excellence in Clinical Teaching Program is associated with meaningful professional growth.

Characteristics of effective clinical teachers identified by dental students: a qualitative study

This qualitative research study identified criteria for clinical teacher quality preferences as perceived by dental students. Third and fourth year dental students at New York University College of Dentistry were given a two question, open-ended survey asking what qualities they liked most and least in a clinical teacher. Responses were collected until data saturation was achieved. A total of 157 respondents provided a total of 995 written comments. Descriptive words within the responses were coded and grouped into key words, according to similar relationships, and further refined into 17 defined categories. Three core themes, Character, Competence and Communication, emerged from these 17 categories, which were validated according to specific references found in the existing educational literature. 'Character' comprised nine of the 17 defined categories: (caring, motivation, empathy, patience, professionalism, available, fairness, happiness, patient-centred) and yielded 59.1% of total student responses; 'Competence' consisted of five categories: knowledgeable, expertise, efficient, skilful, effective (29.2%); and 'Communication' represented the remaining three categories: feedback, approachable and interpersonal communication (11.7%). Positive and negative responses related to the defined category of caring were cited by 59.2% of all students. Motivation was the next highest category, cited by 45.9% of students. Non-cognitive attributes, especially those in the Character theme, comprised the majority of student comments. Because students' perceptions are so critical to understanding clinical teaching effectiveness in dental education, these findings can be used to develop assessments to measure clinical teaching effectiveness, to create criteria for the hiring and promotion of clinical faculty and to plan faculty development programming.

Using multiple measures to evaluate a dental faculty development program

INTRODUCTION

The formal preparation of dental professionals for teaching is increasingly seen as essential to enhance teacher effectiveness and student learning and to promote curricular initiatives. As a result, many dental schools have implemented a variety of faculty development programming. There is a body of literature that describes these programmes, but there is limited rigorous evaluation of them. The use of multiple measures of evaluation helps to compensate for potential inadequacies of individual methods. Analyses with multiple measures provide a more comprehensive view of whether a programme is achieving its learning outcomes.

MATERIALS AND METHODS

A dental faculty development programme, Class Advanced Clinical Teaching Scholars (ACTS), at New York University College of Dentistry (NYUCD) was evaluated with four different measures: pre- and post-programme tests of participants' level of relevant pedagogical knowledge, pre- and post-programme objective structured teaching examinations (OSTEs), pre- and post-programme self-assessments of teaching abilities and post-programme participant satisfaction surveys. Two of the measures used a comparison group of faculty.

RESULTS

Results revealed that the Class ACTS participants significantly improved their knowledge; observed teaching performance in most teaching domains tested showed significant improvement; there was no significant change in self-assessed teaching abilities after participation; and the course was viewed positively by the participants.

CONCLUSION

Class ACTS, an advanced dental faculty development course, has been successfully implemented and evaluated with the use of multiple measures.

The role of social media in dental education

Social media, also known as Web 2.0, includes a set of web-based technologies in which users actively share and create content through open collaboration. The current students in dental school are Millennial learners who are comfortable using social media, such as Facebook and Twitter, for both socialization and learning. This article defines and explores the range of Web 2.0 technologies available for use in dental education, addresses their underlying pedagogy, and discusses potential problems and barriers to their implementation.

Creating an objective structured teaching examination to evaluate a dental faculty development program

This article describes the creation of an objective structured teaching examination (OSTE) to assess a dental faculty development program. An OSTE is a performance-based measure that utilizes standardized students and is designed to measure observable teaching skills. In spring 2010, the authors developed, implemented, and evaluated an OSTE to assess a New York University College of Dentistry (NYUCD) faculty development program, Class ACTS (Advanced Clinical Teaching Scholars). They created a three-station OSTE to measure changes in teaching skills resulting from participation in Class ACTS. Dental student teaching assistants were trained to act as standardized students and patients and to use the rating forms. The faculty members' OSTE scores and ratings increased after participating in the Class ACTS program in all fifteen teaching domains tested, and statistically significant improvements occurred in nine of the fifteen domains. A search of the relevant literature suggests that this is the first time that an OSTE has been used to assess a faculty development program in dental education. This study's results appear to support NYUCD's faculty development efforts to improve the teaching skills of its faculty members.

Role of dental professional identification and referral of victims of domestic violence

Dental professionals can play an important role in identifying and referring victims of domestic violence. Since most of the injuries sustained by victims occur in the head and neck region, dentists are uniquely positioned to help address this enormous public health issue. Unfortunately, dentists are the least likely of all health professionals to identify and refer victims of abuse. Much of this failure may be attributed to a lack of knowledge. This article provides an overview of the types and indicators of abuse, information about screening and interviewing victims, and referral resources.

A survey of U.S. dental school programs that help students consider academic careers

The faculty shortage in dental education has been reported for many years and is expected to increase. Some dental schools have developed "grow your own" programs that introduce students to academic careers and give them teaching experiences. These programs generally consist of teaching assistant, fellowship, and peer tutoring opportunities. In this study, a nineteen-item survey was sent to fifty-six U.S. dental schools to determine the extent to which such programs were being implemented. Thirty-six out of fifty-six dental schools responded, a response rate of 64 percent. Twenty-five schools or 69 percent of the respondents reported the existence of a formal teaching assistant, fellowship, or peer tutoring program in which students teach in some capacity. The main reasons reported for implementing these programs were to expose students to academia and to address faculty shortages. The respondents reported that positive outcomes for dental student teachers and their students were academic benefits and increased interest in academic life. Among the barriers reported were securing faculty and financial support and problems with scheduling.

Community-based dental education and the importance of faculty development

Community-based dental education offers a variety of positive learning experiences for students while providing needed dental services for the underserved. More dental students are being instructed by a growing body of largely volunteer community-based faculty who practice in a wide range of community settings including community hospitals and clinics, nursing homes, and private practices. These geographically dispersed instructors may have little experience as educators. Their practice styles and their motivation to improve teaching effectiveness are likely to differ from the styles and motivation of school-based faculty members. Moreover, many dental schools have begun to emphasize practices that may be unfamiliar to community-based faculty such as evidence-based practice. Providing faculty development for them is challenging, yet crucial to the success of these programs and dental education in general. Fundamental elements that must be considered for effective community faculty development programming include fostering a culture of respect between school-based and community faculty members, basing programs on the actual needs of these educators, integrating principles of adult learning theory, and establishing ongoing institutional support. This article provides background on this movement, reviews the literature for faculty development programs geared specifically to community-based educators, makes recommendations for development programs for these dental educators, and includes suggestions for future research.

Use of an action learning model to create a dental faculty development program

Dental educators are often talented practitioners who may have little knowledge of educational concepts and current teaching modalities. Dental schools have recognized the need to offer instruction in teaching skills to their clinical faculty members to support their roles as educators. Since 2005, New York University College of Dentistry (NYUCD) Office of Professional Development has sponsored the Excellence in Clinical Teaching Program, an introductory program in pedagogy and teaching skills. The Action Learning model was used to drive development and implementation of Class ACTS (Advanced Clinical Teaching Scholars), a new advanced teaching skills program. Action Learning is a collaborative educational approach that has its origins in the business world. The learning is problem-driven and occurs in a supportive and reflective environment. The Action Learning approach culminated in a seminar series, Class ACTS, that offers an in-depth opportunity for faculty members to sustain and improve their teaching skills in a small-group setting. Class ACTS is open to NYUCD faculty members who have successfully completed NYUCD's Excellence in Clinical Teaching Program or a comparable program and have a basic background in pedagogy.

Use of botulinum toxin in dentistry

A growing number of dentists are providing botulinum toxin to patients. The research presented here outlines potential uses of Botox related to oral health and facial problems as compared to traditional treatment methods. The administration of Botox (historically done by dermatologists and neurologists) may fall under dentists' jurisdiction, as their training and knowledge encompasses the entire head and neck. A review is made of the literature, based on Ovid and PubMed searches, selecting articles describing the injection of botulinum toxin A in areas related to the oral cavity and the face, excluding cosmetic purposes.

Integrating dental anatomy and biomaterials: an innovative use of composite resin

As part of the new integrated curriculum at the New York University College of Dentistry, a pilot program uses composite resins to teach dental anatomy. The Department of Biomaterials and Biomimetics, in conjunction with the Department of Cariology and Operative Dentistry, has created a teaching module to replicate the morphology of a central incisor through the manipulation and placement of a composite resin.

Determinants of disability after lower extremity fracture

BACKGROUND

Factors influencing the progression of physical impairment to patient-perceived disability are not well known. We sought to better understand this relationship in the setting of injury.

METHODS

We followed a cohort of 302 patients with lower extremity fractures over a 1-year period. Physical impairment was assessed by range of motion, strength, and pain. Range of motion and strength were assessed together as a proportion of normal function of the extremity (impairment score). Pain was assessed using a Visual Analogue Scale (VAS) pain score. Disability was assessed using the Sickness Impact Profile (SIP), a widely used measure of patient-perceived limitations of everyday activities attributable to illness. The SIP was administered during hospitalization to assess preinjury baseline. Impairment assessment and readministration of the SIP were performed at 12 months after injury.

RESULTS

Impairment in leg function (range of motion and strength) was highly correlated (p < 0.001) with overall SIP score at 12 months, but accounted for only 23% of the variance in overall SIP scores. Likewise, VAS pain score was highly correlated (p < 0.001) with overall SIP score at 12 months, but accounted for only 29% of the variance in overall SIP scores. In a multivariate linear regression analysis, variables that were independently associated with overall SIP score included impairment score, VAS pain score, preinjury SIP, poverty status, education status, social support, having hired a lawyer, and involvement with workers' compensation. These variables accounted for 52% of the variance in overall SIP scores at 12 months.

CONCLUSION

The degree of physical impairment accounts for only a small amount of the variance in disability from lower extremity fracture. Identifiable patient characteristics including age, socioeconomic status, preinjury health, and social support together with impairment account for over half of the variance in long-term disability. Further research is needed to increase understanding of other factors that influence the progression of impairment to disability, especially those factors that may be amenable to intervention.

Evidence for a single-spin azimuthal asymmetry in semi-inclusive pion electroproduction

Single-spin asymmetries for semi-inclusive pion production in deep-inelastic scattering have been measured for the first time. A significant target-spin asymmetry of the distribution in the azimuthal angle straight phi of the pion relative to the lepton scattering plane was formed for pi(+) electroproduction on a longitudinally polarized hydrogen target. The corresponding analyzing power in the sinstraight phi moment of the cross section is 0.022+/-0.005+/-0.003. This result can be interpreted as the effect of terms in the cross section involving chiral-odd spin distribution functions in combination with a chiral-odd fragmentation function that is sensitive to the transverse polarization of the fragmenting quark.

Testing promoter activity in the trypanosome genome: isolation of a metacyclic-type VSG promoter, and unexpected insights into RNA polymerase II transcription

In trypanosomes, most genes are arranged in polycistronic transcription units. Individual mRNAs are generated by 5'-trans splicing and 3' polyadenylation. Remarkably, no regulation of RNA polymerase II transcription has been detected although many RNAs are differentially expressed during kinetoplastid life cycles. Demonstration of specific class II promoters is complicated by the difficulty in distinguishing between genuine promoter activity and stimulation of trans splicing. Using vectors that were designed to allow the detection of low promoter activities in a transcriptionally silent chromosomal context, we isolated a novel trypanosome RNA polymerase I promoter. We were however unable to detect class II promoter activity in any tested DNA fragment. We also integrated genes which were preceded by a T3 promoter into the genome of cells expressing bacteriophage T3 polymerase: surprisingly, transcription was alpha-amanitin sensitive. One possible interpretation of these results is that in trypanosomes, RNA polymerase II initiation is favored by genomic accessibility and double-strand melting.

Opinions of dental consultants on the standard of referral letters in dentistry

AIM

To ascertain the views of dental consultants on the relative importance of a range of topics relevant to specialist referral.

SUBJECTS

200 randomly selected dental consultants working in the UK in 1995.

MAIN OUTCOME MEASURES

Data items which referral letters should contain; standard of referral letters; appropriate reasons for referral; how referrals could be improved; should restrictions be placed on specialist referrals.

RESULTS

161 replies were received. Overall there was only slight variation between specialities with regard to data items, appropriateness of referral and standard of referral letter. The perceived standard of referral letters was adequate or better on 76% of occasions; 21% were deemed to be of a poor standard; 2% were described as appalling.

CONCLUSIONS

A Section 63 course on how to refer competently could be of benefit. Consultants were generally not in favour of restricting referrals to them.

Operative treatment of fractures of the tibial plafond. A randomized, prospective study

We performed a randomized, prospective study to compare the results of two methods for the operative fixation of fractures of the tibial plafond. Surgeons were assigned to a group on the basis of the operation that they preferred (randomized-surgeon design). In the first group, which consisted of eighteen patients, open reduction and internal fixation of both the tibia and the fibula was performed through two separate incisions. An additional patient, who had an intact fibula, had fixation of the tibia only through an anteromedial incision. The second group consisted of twenty patients who were managed with external fixation with or without limited internal fixation (a fibular plate or tibial interfragmentary screws). Ten (26 per cent) of the thirty-nine fractures were open, and seventeen (44 per cent) were type III according to the classification of Rüedi and Allgöwer. There were fifteen operative complications in seven patients who had been managed with open reduction and internal fixation and four complications in four patients who had been managed with external fixation. All but four of the complications were infection or dehiscence of the wound that had developed within four months after the initial operation. The complications after open reduction and internal fixation tended to be more severe, and amputation was eventually done in three patients in this group. At a minimum of two years postoperatively (average, thirty-nine months; range, twenty-five to fifty-one months), the average clinical score was lower for the patients who had had a type-II or III fracture, regardless of the type of treatment. With the numbers available, no significant difference was found between the average clinical scores for the two groups. All of the patients, in both groups, who had had a type-II or III fracture had some degree of osteoarthrosis on plain radiographs at the time of the latest follow-up. With the numbers available, there was no significant difference between the two groups with regard to the osteoarthrotic changes. We concluded that external fixation is a satisfactory method of treatment for fractures of the tibial plafond and is associated with fewer complications than internal fixation.

Long-term outcomes after lower extremity trauma

Previous studies have shown that over one-quarter of patients who were working before a severe lower extremity fracture had not returned to work by 12 months after injury. Disabilities also persisted in household management, recreation, and social interaction. The objective of this study was to determine whether recovery extended beyond 12 months. Three hundred nineteen patients who were previously working and were treated at three level I trauma centers for a severe lower extremity fracture were prospectively followed at 3, 6, and 12 months after injury. Patients were queried at each follow-up about their work status and completed the Sickness Impact Profile (SIP) at 6 and 12 months. The SIP is a widely used and well validated measure of general health status; it was used in this study to measure functional recovery across several domains of daily living. Patients who had not recovered by 12 months (i.e., 204 who were not working, working with limitations, or had limitations in performing other daily activities as measured by elevated scores on the SIP) were contacted again at 30 months and asked to complete an interview and the SIP. At 30 months, an estimated 82% of the study patients had returned to work (compared to 72% at 12 months). SIP scores improved only slightly from 6.4 at 12 months to 5.7 at 30 months. At 30 months, 64% of the patients had no disability (SIP scores less than 4), 17% had mild disability (SIP scores of 4 to 9), 12% had moderate disability (SIP scores of 10 to 19), and 7% had severe disability (SIP scores of 20 or higher). Although the majority of patients with persistent disabilities at 30 months had residual physical impairments at 12 months, the extent of impairment did not fully explain why some people had and had not recovered at 30 months after injury. The results confirm those of other studies that conclude that overall, outcomes after serious trauma are good when appropriate trauma and rehabilitation care are rendered. However, a minority of patients still report limitations at 30 months after injury, with one-fifth not returning to work.

The Sickness Impact Profile as a tool to evaluate functional outcome in trauma patients

Because the ultimate goal of trauma care is to restore injured patients to their former functional status, reliable evaluation of functional status is needed to assess fully the effectiveness of trauma care. We hypothesized that the Sickness Impact Profile (SIP), a widely used measure of general health status, would be a useful tool to evaluate the long-term functional outcome of trauma patients and that the SIP would identify unexpected problems in the recovery process and groups of patients at high risk for long-term disability. A prospective cohort of 329 patients with lower extremity fractures admitted to three level I trauma centers were interviewed using SIP at 6 and 12 months postinjury. Patients with major neurologic injuries were excluded. Overall SIP scores and each of the component subscores may range from 0 (no disability) to 100. In this series, the mean overall SIP was 9.5 at 6 months and 6.8 at 12 months, compared with a preinjury baseline of 2.5. At 12 months, 52% of patients had no disability (SIP 0 to 3), 23% mild disability (4 to 9), 16% moderate disability (10 to 19), and 9% severe disability ( > or = 20). Disability was widely distributed across the spectrum of activities of daily living, including physical functioning (mean score of 5.5), psychosocial health (mean score of 5.5), sleeping (mean score of 10.0), and work (mean score of 21.0). The SIP scores did not correlate with Injury Severity Score.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of concomitant chondral injuries accompanying operatively reduced malleolar fractures

The best clinical results in the treatment of malleolar fractures occur when an anatomic reduction is obtained and maintained until the fractures are healed. Ankle pain and/or tibio-talar arthrosis has been reported despite anatomic surgical reduction and stable fixation of the malleoli. This may be due to unrecognized injuries to the cartilaginous surfaces of the tibio-talar joint. Between 1984 and 1987, 63 patients with isolated closed malleolar fractures underwent open reduction and internal fixation using standard AO techniques. Each patient had inspection of the entire talar dome during surgery. There were seven type A, 37 type B, and 19 type C fractures. Thirty-one patients (49%) had injuries to the talar dome cartilage, ranging from mild scuffing to free osteochondral fragments. Twenty-five patients were available for a follow-up evaluation at an average of 25 months after surgery. Thirteen patients had some complaints of pain, eight of whom had talar dome chondral injuries. The overall results, including functional status and ankle range of motion, were significantly poorer in patients with talar dome chondral injuries (p less than or equal to 0.03 and p less than or equal to 0.042, respectively).