Large variations in the practice patterns of surgical antiseptic preparation solutions in patients with open and closed extremity fractures : a cross-sectional survey

Surgically-managed fractures, particularly open fractures, are associated with high rates of surgical site infections (SSIs). To reduce the risk of an SSI, orthopaedic surgeons routinely clean open fracture wounds in the emergency department (ED) and then apply a bandage to the open wound. Prior to the surgical incision, it is standard practice to prepare the fracture region with an antiseptic skin solution as an additional SSI prevention strategy. Multiple antiseptic solutions are available. To explore the variation in practice patterns among orthopaedic surgeons regarding antiseptic solution use in the ED and antiseptic preparatory techniques for fracture surgery. We developed a 27-item survey and surveyed members of several orthopaedic associations. Two hundred and-ten surveys were completed. 71.0% of respondents irrigate the open wound and skin in the ED, primarily with saline alone (59.7%) or iodine-based solutions (32.9%). 90.5% of responders indicated that they dress the open wound in the ED, with 41.0% applying a saline-soaked bandage and 33.7% applying an iodine-soaked dressing (33.7%). In their surgical preparation of open fractures, 41.0% of respondents used an iodine-based solution, 26.7% used a chlorhexidine gluconate (CHG)-based solution, and 31.4% used a combination of the two. In closed fractures, 43.8% of respondents used a CHG-based solution, 28.1% used an iodine-based solution, and 27.1% used a combination. Despite theoretical concerns about the use of alcohol in open wounds, 51.4% used alcohol-based solutions or alcohol alone during skin preparation of open fractures. A lack of consensus exists regarding use of antiseptic surgical preparation solutions for fractures. High-quality clinical research is needed to assess the effectiveness of different surgical antiseptic preparation solutions on patient outcomes in fracture populations. The online version of this article (10.1186/s13756-018-0440-z) contains supplementary material, which is available to authorized users

miR-27b Targets KSRP to Coordinate TLR4-Mediated Epithelial Defense against Cryptosporidium parvum Infection

Cryptosporidium is a protozoan parasite that infects the gastrointestinal epithelium and causes a diarrheal disease. Toll-like receptor (TLR)- and NF-κB-mediated immune responses from epithelial cells, such as production of antimicrobial peptides and generation of reactive nitrogen species, are important components of the host's defense against cryptosporidial infection. Here we report data demonstrating a role for miR-27b in the regulation of TLR4/NF-κB-mediated epithelial anti-Cryptosporidium parvum responses. We found that C. parvum infection induced nitric oxide (NO) production in host epithelial cells in a TLR4/NF-κB-dependent manner, with the involvement of the stabilization of inducible NO synthase (iNOS) mRNA. C. parvum infection of epithelial cells activated NF-κB signaling to increase transcription of the miR-27b gene. Meanwhile, downregulation of KH-type splicing regulatory protein (KSRP) was detected in epithelial cells following C. parvum infection. Importantly, miR-27b targeted the 3′-untranslated region of KSRP, resulting in translational suppression. C. parvum infection decreased KSRP expression through upregulating miR-27b. Functional manipulation of KSRP or miR-27b caused reciprocal alterations in iNOS mRNA stability in infected cells. Forced expression of KSRP and inhibition of miR-27b resulted in an increased burden of C. parvum infection. Downregulation of KSRP through upregulating miR-27b was also detected in epithelial cells following LPS stimulation. These data suggest that miR-27b targets KSRP and modulates iNOS mRNA stability following C. parvum infection, a process that may be relevant to the regulation of epithelial anti-microbial defense in general

Fixation Using Alternative Implants for the Treatment of Hip Fractures (FAITH-2): The Clinical Outcomes of a Multicenter 2 × 2 Factorial Randomized Controlled Pilot Trial in Young Femoral Neck Fracture Patients

Objective: To assess whether the fixation method and vitamin D supplementation affect the risk of patient-important outcomes within 12 months of injury in nongeriatric femoral neck fracture patients. Design: A pilot factorial randomized controlled trial. Setting: Fifteen North American clinical sites. Participants: Ninety-one adults 18–60 years of age with a femoral neck fracture requiring surgical fixation. Intervention: Participants were randomized to a surgical intervention (sliding hip screw or cancellous screws) and a vitamin D intervention (vitamin D3 4000 IU daily vs. placebo for 6 months). Main Outcome Measurements: The primary clinical outcome was a composite of patient-important complications (reoperation, femoral head osteonecrosis, severe femoral neck malunion, and nonunion). Secondary outcomes included fracture-healing complications and radiographic fracture healing. Results: Eighty-six participants with a mean age of 41 years were included. We found no statistically significant difference in the risk of patient-important outcomes between the surgical treatment arms (hazard ratio 0.90, 95% confidence interval 0.40–2.02, P = 0.80) and vitamin D supplementation treatment arms (hazard ratio 0.96, 95% confidence interval 0.42–2.18, P = 0.92). Conclusions: These pilot trial results continue to describe the results of current fixation implants, inform the challenges of improving outcomes in this fracture population, and may guide future vitamin D trials to improve healing outcomes in young fracture populations. Although the pilot trial was not adequately powered to detect treatment effects, publishing these results may facilitate future meta-analyses on this topic. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence

Intraperitoneal drain placement and outcomes after elective colorectal surgery: international matched, prospective, cohort study

Despite current guidelines, intraperitoneal drain placement after elective colorectal surgery remains widespread. Drains were not associated with earlier detection of intraperitoneal collections, but were associated with prolonged hospital stay and increased risk of surgical-site infections.Background Many surgeons routinely place intraperitoneal drains after elective colorectal surgery. However, enhanced recovery after surgery guidelines recommend against their routine use owing to a lack of clear clinical benefit. This study aimed to describe international variation in intraperitoneal drain placement and the safety of this practice. Methods COMPASS (COMPlicAted intra-abdominal collectionS after colorectal Surgery) was a prospective, international, cohort study which enrolled consecutive adults undergoing elective colorectal surgery (February to March 2020). The primary outcome was the rate of intraperitoneal drain placement. Secondary outcomes included: rate and time to diagnosis of postoperative intraperitoneal collections; rate of surgical site infections (SSIs); time to discharge; and 30-day major postoperative complications (Clavien-Dindo grade at least III). After propensity score matching, multivariable logistic regression and Cox proportional hazards regression were used to estimate the independent association of the secondary outcomes with drain placement. Results Overall, 1805 patients from 22 countries were included (798 women, 44.2 per cent; median age 67.0 years). The drain insertion rate was 51.9 per cent (937 patients). After matching, drains were not associated with reduced rates (odds ratio (OR) 1.33, 95 per cent c.i. 0.79 to 2.23; P = 0.287) or earlier detection (hazard ratio (HR) 0.87, 0.33 to 2.31; P = 0.780) of collections. Although not associated with worse major postoperative complications (OR 1.09, 0.68 to 1.75; P = 0.709), drains were associated with delayed hospital discharge (HR 0.58, 0.52 to 0.66; P < 0.001) and an increased risk of SSIs (OR 2.47, 1.50 to 4.05; P < 0.001). Conclusion Intraperitoneal drain placement after elective colorectal surgery is not associated with earlier detection of postoperative collections, but prolongs hospital stay and increases SSI risk

The Changing Landscape for Stroke\ua0Prevention in AF: Findings From the GLORIA-AF Registry Phase 2

Background GLORIA-AF (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation) is a prospective, global registry program describing antithrombotic treatment patterns in patients with newly diagnosed nonvalvular atrial fibrillation at risk of stroke. Phase 2 began when dabigatran, the first non\u2013vitamin K antagonist oral anticoagulant (NOAC), became available. Objectives This study sought to describe phase 2 baseline data and compare these with the pre-NOAC era collected during phase 1. Methods During phase 2, 15,641 consenting patients were enrolled (November 2011 to December 2014); 15,092 were eligible. This pre-specified cross-sectional analysis describes eligible patients\u2019 baseline characteristics. Atrial fibrillation disease characteristics, medical outcomes, and concomitant diseases and medications were collected. Data were analyzed using descriptive statistics. Results Of the total patients, 45.5% were female; median age was 71 (interquartile range: 64, 78) years. Patients were from Europe (47.1%), North America (22.5%), Asia (20.3%), Latin America (6.0%), and the Middle East/Africa (4.0%). Most had high stroke risk (CHA2DS2-VASc [Congestive heart failure, Hypertension, Age  6575 years, Diabetes mellitus, previous Stroke, Vascular disease, Age 65 to 74 years, Sex category] score  652; 86.1%); 13.9% had moderate risk (CHA2DS2-VASc = 1). Overall, 79.9% received oral anticoagulants, of whom 47.6% received NOAC and 32.3% vitamin K antagonists (VKA); 12.1% received antiplatelet agents; 7.8% received no antithrombotic treatment. For comparison, the proportion of phase 1 patients (of N = 1,063 all eligible) prescribed VKA was 32.8%, acetylsalicylic acid 41.7%, and no therapy 20.2%. In Europe in phase 2, treatment with NOAC was more common than VKA (52.3% and 37.8%, respectively); 6.0% of patients received antiplatelet treatment; and 3.8% received no antithrombotic treatment. In North America, 52.1%, 26.2%, and 14.0% of patients received NOAC, VKA, and antiplatelet drugs, respectively; 7.5% received no antithrombotic treatment. NOAC use was less common in Asia (27.7%), where 27.5% of patients received VKA, 25.0% antiplatelet drugs, and 19.8% no antithrombotic treatment. Conclusions The baseline data from GLORIA-AF phase 2 demonstrate that in newly diagnosed nonvalvular atrial fibrillation patients, NOAC have been highly adopted into practice, becoming more frequently prescribed than VKA in Europe and North America. Worldwide, however, a large proportion of patients remain undertreated, particularly in Asia and North America. (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients With Atrial Fibrillation [GLORIA-AF]; NCT01468701

The orthopaedic trauma patient experience: a qualitative case study of orthopaedic trauma patients in Uganda.

The disability adjusted life years (DALYs) associated with injuries have increased by 34% from 1990 to 2010, making it the 10th leading cause of disability worldwide, with most of the burden affecting low-income countries. Although disability from injuries is often preventable, limited access to essential surgical services contributes to these increasing DALY rates. Similar to many other low- and middle-income countries (LMIC), Uganda is plagued by a growing volume of traumatic injuries. The aim of this study is to explore the orthopaedic trauma patient's experience in accessing medical care in Uganda and what affects the injury might have on the socioeconomic status for the patient and their dependents. We also evaluate the factors that impact an individual's ability to access an appropriate treatment facility for their traumatic injury. Semi-structured interviews were conducted with patients 18 year of age or older admitted with a fractured tibia or femur at Mulago National Referral Hospital in Kampala, Uganda. As limited literature exists on the socioeconomic impacts of disability from trauma, we designed a descriptive qualitative case study, using thematic analysis, to extract unique information for which little has been previously been documented. This methodology is subject to less bias than other qualitative methods as it imposes fewer preconceptions. Data analysis of the patient interviews (n = 35) produced over one hundred codes, nine sub-themes and three overarching themes. The three overarching categories revealed by the data were: 1) the importance of social supports; 2) the impact of and on economic resources; and 3) navigating the healthcare system. Limited resources to fund the treatment of orthopaedic trauma patients in Uganda leads to reliance of patients on their friends, family, and hospital connections, and a tremendous economic burden that falls on the patient and their dependents

The socioeconomic impact of orthopaedic trauma: A systematic review and meta-analysis

The overall objective of this study was to determine the patient-level socioeconomic impact resulting from orthopaedic trauma in the available literature. The MEDLINE, Embase, and Scopus databases were searched in December 2019. Studies were eligible for inclusion if more than 75% of the study population sustained an appendicular fracture due to an acute trauma, the mean age was 18 through 65 years, and the study included a socioeconomic outcome, defined as a measure of income, employment status, or educational status. Two independent reviewers performed data extraction and quality assessment. Pooled estimates of the socioeconomic outcome measures were calculated using random-effects models with inverse variance weighting. Two-hundred-five studies met the eligibility criteria. These studies utilized five different socioeconomic outcomes, including return to work (n = 119), absenteeism days from work (n = 104), productivity loss (n = 11), income loss (n = 11), and new unemployment (n = 10). Pooled estimates for return to work remained relatively consistent across the 6-, 12-, and 24-month timepoint estimates of 58.7%, 67.7%, and 60.9%, respectively. The pooled estimate for mean days absent from work was 102.3 days (95% CI: 94.8-109.8). Thirteen-percent had lost employment at one-year post-injury (95% CI: 4.8-30.7). Tremendous heterogeneity (I2>89%) was observed for all pooled socioeconomic outcomes. These results suggest that orthopaedic injury can have a substantial impact on the patient's socioeconomic well-being, which may negatively affect a person's psychological wellbeing and happiness. However, socioeconomic recovery following injury can be very nuanced, and using only a single socioeconomic outcome yields inherent bias. Informative and accurate socioeconomic outcome assessment requires a multifaceted approach and further standardization

Analysis of Patient Income in the 5 Years Following a Fracture Treated Surgically

Importance: Orthopedic injury is assumed to bear negative socioeconomic consequences. However, the magnitude and duration of a fracture's impact on patient income and social insurance benefits remain poorly quantified. Objective: To characterize the association between orthopedic injury and patient income using state tax records. Design, Setting, and Participants: This cohort study included adult patients surgically treated for an orthopedic fracture at a US academic trauma center from January 2003 through December 2014. Hospital data were linked to individual-level state tax records using a difference-in-differences analysis performed from November 2019 through August 2020. The control group comprised of data resampled from fracture patients at least 6 years prior to injury. Exposures: An operatively treated fracture of the appendicular skeleton. Main Outcomes and Measures: The primary outcome was individual annual earnings up to 5 years postinjury. Secondary outcomes included annual household income and US Social Security benefits for 5 years postinjury and catastrophic wage loss within 2 years of injury. Results: A total of 9997 fracture patients (mean [SD] age, 44.6 [18.9] years; 6725 [67.3%] men) to 34 570 prefracture control participants (mean [SD] age, 40.0 [20.5] years; 21 666 [62.7%] men). The median (interquartile range) of preinjury wage earnings was $16 847 ($0 to $52 221). The mean annual decline in individual earnings during the 5 years following injury was$9865 (95% CI, -$10 686 to -$8862). Annual household income declined by $5259 (95$6337 to -$4181) over the same period. A fracture was associated with a$206 (95% CI, $147 to$265) mean annual increase in Social Security benefits in the 5 years after injury. An injury increased the risk of catastrophic wage loss by 11.6% (95% CI, 10.5% to 12.7%). Substantial relative income loss was observed in patients with preinjury earnings in the top 3 quartiles, but changes in income were negligible for patients with preinjury earnings in the bottom quartile (19%; 95% CI, -4% to 48%). Conclusions and Relevance: In this cohort study of patients surgically treated for an orthopedic fracture at a US academic trauma center, fractures were associated with substantial individual and household income loss up to 5 years after injury, and 1 in 5 patients sustained catastrophic income loss in the 2 years after fracture. Gains in Social Security benefits offset less than 10% of annual income losses