Open fractures of the tibia: a national, regional and individual perspective

Introduction Open tibial fractures are complex high energy injuries, associated with soft tissue loss and contamination; they are amongst the most severe injuries seen in orthopaedic practice. Modern practice demonstrates a tendency to reconstruct severely injured limbs; yet despite the use of aggressive protocols, recovery is often incomplete with long-term implications for patients. Robust research in this field is limited; much of the published work is based on single institutional experiences and hampered by poor study design. Ultimately, there will be a role for randomised controlled trials in determining the best interventions for these patients; although research questions in randomised controlled trials must be set on firm foundations with comprehensive work undertaken to understand current perspectives. These perspectives are currently not clearly outlined in the literature where; epidemiological patterns, the limits of established practice and patient views are all poorly represented. The aim of this thesis is to pursue answers to these questions, with an overall purpose of supporting the future development of high quality research in open tibial fractures. Methods A mixed-methods study with a sequential explanatory study design. Descriptive statistics, sensitivity analysis and generalised linear models were used to analyse data from two large datasets. The two datasets included data from the Trauma Audit Research Network (TARN); the national registry for trauma which contains comprehensive characterisation of patients and care-pathways; and a detailed local injury register from the East Midlands Trauma Centre which holds linked micro-costings and a cross-sectional patient-reported outcome measures (PROMS) dataset. A qualitative systematic review was performed using Joanna Briggs Institute methodology, and the results of these three studies were triangulated to inform the design of a qualitative study considering patient perspective. The qualitative study used semi-structured interviews with individuals who had sustained an open tibial fracture 12-72 months ago and were analysed using framework and cross-case analysis. Results Based on an analysis of 7994 cases from the TARN dataset, crude incidence rate of open tibial fracture was 2.85 per 100,000 persons per year. Injury occurred most frequently in males aged 25-30; however, incidence was 15% higher in patients aged over 65 when compared to the 15-39 age group (IRR: 1.15 (1.09-1.22). A fully adjusted model identified the mortality rate was two times greater in patients with comorbidities (OR: 2.34, CI: 1.60 – 3.42). In a further fully adjusted model including 2157 Gustilo 3B or 3C fractures, time to soft tissue coverage was related to wound complications. The proportion of individuals experiencing early inpatient wound complication increased by 0.3% per hour until definitive soft tissue cover (OR: 1.003, (CI: 1.001 - 1.004); other variables in this model relating to the injury or treatment were mostly not significant. The study highlighted the challenges of applying a research question to a dataset collected with a different aim. The regional injury dataset included 212 individuals. The complication rate was 24% with mean time to revision surgery at 260 days. One year after injury, individuals reported a 26% (p<0.01) reduction in quality of life, and a 30% increase in disability (p<0.01). The mean cost of treatment was £27312, however, there was significant variation in cost dependant on injuries, treatment (p<0.05) and complications (p<0.05). The qualitative study included 26 individuals who described recovery with parallel physical and psychological narratives. Regaining mobility was a priority for individuals who perceived this to be the gateway to returning to their former roles and responsibilities; whilst mobility was important, many symptoms were reported. The breakdown of routine and purpose that came after the accident was devastating and challenging to navigate. Hope was difficult to sustain due to unknown outcomes, although coping strategies such as goal setting and seeking personal support were important psychological mediators. Experience of recovery differed dependant on fixation strategy; with ring-fixators appearing more difficult to tolerate with broad social consequences. Age was also relevant; the gravity of these challenges was exacerbated for younger individuals, who did not have the financial stability or social capital to endure this life-changing injury without long-term social ramifications. Conclusion: This thesis provides a clear national picture of the epidemiology, care pathways and costs associated with open tibial fracture, and provides insight into the implications of this injury for individuals. The thesis offers a case for improving surgical care for individuals with an open tibial fracture; but recognises that this will only be achieved with carefully planned research that adequately controls for variation in these injuries. In addition, modest restructuring of care-pathways to acknowledge the psychosocial implications of these injuries could dramatically improve patient experience with minimal cost

Open fractures of the tibia: a national, regional and individual perspective

Introduction Open tibial fractures are complex high energy injuries, associated with soft tissue loss and contamination; they are amongst the most severe injuries seen in orthopaedic practice. Modern practice demonstrates a tendency to reconstruct severely injured limbs; yet despite the use of aggressive protocols, recovery is often incomplete with long-term implications for patients. Robust research in this field is limited; much of the published work is based on single institutional experiences and hampered by poor study design. Ultimately, there will be a role for randomised controlled trials in determining the best interventions for these patients; although research questions in randomised controlled trials must be set on firm foundations with comprehensive work undertaken to understand current perspectives. These perspectives are currently not clearly outlined in the literature where; epidemiological patterns, the limits of established practice and patient views are all poorly represented. The aim of this thesis is to pursue answers to these questions, with an overall purpose of supporting the future development of high quality research in open tibial fractures. Methods A mixed-methods study with a sequential explanatory study design. Descriptive statistics, sensitivity analysis and generalised linear models were used to analyse data from two large datasets. The two datasets included data from the Trauma Audit Research Network (TARN); the national registry for trauma which contains comprehensive characterisation of patients and care-pathways; and a detailed local injury register from the East Midlands Trauma Centre which holds linked micro-costings and a cross-sectional patient-reported outcome measures (PROMS) dataset. A qualitative systematic review was performed using Joanna Briggs Institute methodology, and the results of these three studies were triangulated to inform the design of a qualitative study considering patient perspective. The qualitative study used semi-structured interviews with individuals who had sustained an open tibial fracture 12-72 months ago and were analysed using framework and cross-case analysis. Results Based on an analysis of 7994 cases from the TARN dataset, crude incidence rate of open tibial fracture was 2.85 per 100,000 persons per year. Injury occurred most frequently in males aged 25-30; however, incidence was 15% higher in patients aged over 65 when compared to the 15-39 age group (IRR: 1.15 (1.09-1.22). A fully adjusted model identified the mortality rate was two times greater in patients with comorbidities (OR: 2.34, CI: 1.60 – 3.42). In a further fully adjusted model including 2157 Gustilo 3B or 3C fractures, time to soft tissue coverage was related to wound complications. The proportion of individuals experiencing early inpatient wound complication increased by 0.3% per hour until definitive soft tissue cover (OR: 1.003, (CI: 1.001 - 1.004); other variables in this model relating to the injury or treatment were mostly not significant. The study highlighted the challenges of applying a research question to a dataset collected with a different aim. The regional injury dataset included 212 individuals. The complication rate was 24% with mean time to revision surgery at 260 days. One year after injury, individuals reported a 26% (p<0.01) reduction in quality of life, and a 30% increase in disability (p<0.01). The mean cost of treatment was £27312, however, there was significant variation in cost dependant on injuries, treatment (p<0.05) and complications (p<0.05). The qualitative study included 26 individuals who described recovery with parallel physical and psychological narratives. Regaining mobility was a priority for individuals who perceived this to be the gateway to returning to their former roles and responsibilities; whilst mobility was important, many symptoms were reported. The breakdown of routine and purpose that came after the accident was devastating and challenging to navigate. Hope was difficult to sustain due to unknown outcomes, although coping strategies such as goal setting and seeking personal support were important psychological mediators. Experience of recovery differed dependant on fixation strategy; with ring-fixators appearing more difficult to tolerate with broad social consequences. Age was also relevant; the gravity of these challenges was exacerbated for younger individuals, who did not have the financial stability or social capital to endure this life-changing injury without long-term social ramifications. Conclusion: This thesis provides a clear national picture of the epidemiology, care pathways and costs associated with open tibial fracture, and provides insight into the implications of this injury for individuals. The thesis offers a case for improving surgical care for individuals with an open tibial fracture; but recognises that this will only be achieved with carefully planned research that adequately controls for variation in these injuries. In addition, modest restructuring of care-pathways to acknowledge the psychosocial implications of these injuries could dramatically improve patient experience with minimal cost

Does achieving the best practice tariff improve outcomes in hip fracture patients? An observational cohort study

Objectives: To determine if the introduction of the best practice tariff (BPT) has improved survival of the elderly hip fracture population, or if achieving BPT results in improved survival for an individual. Setting: A single university-affiliated teaching hospital. Participants: 2,541 patients aged over 60 admitted with a neck of femur fracture between 2008 and 2010 and from 2012 to 2014 were included, to create two cohorts of patients, before and after the introduction of BPT. The post-BPT cohort was divided into two groups, those who achieved the criteria and those who did not. Primary and Secondary Outcome Measures: Primary outcomes of interest were differences in mortality across cohorts. Secondary analysis was performed to identify associations between individual BPT criteria and mortality. Results: The introduction of BPT did not significantly alter overall 30-mortality in the hip fracture population (8.3% pre-BPT vs 10.0% post-BPT; p = 0.128). Neither was there a significant reduction in length of stay (15 days (IQR 9-21) pre-BPT vs 14 days (IQR 11-22); p=0.236). However, the introduction of BPT was associated with a reduction in the time from admission to theatre (median 44hours pre-BPT (IQR 24-44) vs 23hours post-BPT (IQR 17-30); p<0.005). 30-day mortality in those who achieved BPT was significantly lower (6.0% vs 21.0% in those who did not achieve-BPT; p < 0.005). There was a survival benefit at one year for those who achieved BPT (28.6% vs 42.0% did not achieve-BPT; p<0.005). Multivariate logistic regression revealed that of the BPT criteria, AMT monitoring and expedited surgery were the only BPT criteria that significantly influenced survival. Conclusion: The introduction of the BPT has not led to a demonstrable improvement in outcomes at organisational level, though other factors may have confounded any benefits. However, patients where BPT criteria are met appear to have improved outcomes

Interrogating the technical, economic and cultural challenges of delivering the PassivHaus standard in the UK.

A peer-reviewed eBook, which is based on a collaborative research project coordinated by Dr. Henrik Schoenefeldt at the Centre for Architecture and Sustainable Environment at the University of Kent between May 2013 and June 2014. This project investigated how architectural practice and the building industry are adapting in order to successfully deliver Passivhaus standard buildings in the UK. Through detailed case studies the project explored the learning process underlying the delivery of fourteen buildings, certified between 2009 and 2013. Largely founded on the study of the original project correspondence and semi-structured interviews with clients, architects, town planners, contractors and manufacturers, these case studies have illuminated the more immediate technical as well as the broader cultural challenges. The peer-reviewers of this book stressed that the findings included in the book are valuable to students, practitioners and academic researchers in the field of low-energy design. It was launched during the PassivHaus Project Conference, held at the Bulb Innovation Centre on the 27th June 2014

Hip fracture outcomes in patients with COPD

Hip fractures are common in patients with COPD and contemporary outcome data is needed. Patients admitted with a hip fracture to one acute trust (2010-2015) were assessed prospectively (UK National Hip Fracture Database audit) and mortality data collected. Of the 4020 patients, 16.2% had a recorded COPD diagnosis. Mortality was significantly greater in patients with COPD compared to non-COPD: 30-days (12.6% vs 7.8%) and 1-year (35.3% vs 25.3%), both p[less than] 0.001 and remained significant after adjustment (aOR at 1 year 1.44 95% CI1.18 -1.76). There is further excess mortality following a hip fracture in those with COPD

Preoperative inflammatory biomarkers reveal renal involvement in postsurgical mortality in hip fracture patients: an exploratory study

BackgroundHip fractures in frail patients result in excess mortality not accounted for by age or comorbidities. The mechanisms behind the high risk of mortality remain undetermined but are hypothesized to be related to the inflammatory status of frail patients.MethodsIn a prospective observational exploratory cohort study of hospitalized frail hip fracture patients, 92 inflammatory markers were tested in pre-operative serum samples and markers were tested against 6-month survival post-hip fracture surgery and incidence of acute kidney injury (AKI). After correcting for multiple testing, adjustments for comorbidities and demographics were performed on the statistically significant markers.ResultsOf the 92 markers tested, circulating levels of fibroblast growth factor 23 (FGF-23) and interleukin-15 receptor alpha (IL15RA), both involved in renal disease, were significantly correlated with 6-month mortality (27.5% overall) after correcting for multiple testing. The incidence of postoperative AKI (25.4%) was strongly associated with 6-month mortality, odds ratio = 10.57; 95% CI [2.76–40.51], and with both markers plus estimated glomerular filtration rate (eGFR)– cystatin C (CYSC) but not eGFR-CRE. The effect of these markers on mortality was significantly mediated by their effect on postoperative AKI.ConclusionHigh postoperative mortality in frail hip fracture patients is highly correlated with preoperative biomarkers of renal function in this pilot study. The effect of preoperative circulating levels of FGF-23, IL15RA, and eGFR-CYSC on 6-month mortality is in part mediated by their effect on postoperative AKI. Creatinine-derived preoperative renal function measures were very poorly correlated with postoperative outcomes in this group

Early motion and directed exercise (EMADE) versus usual care post ankle fracture fixation: study protocol for a pragmatic randomised controlled trial

Background: Following surgical fixation of ankle fractures, the traditional management has included immobilisation for 6 weeks in a below-knee cast. However, this can lead to disuse atrophy of the affected leg and joint stiffness. While early rehabilitation from 2 weeks post surgery is viewed as safe, controversy remains regarding its benefits. We will compare the effectiveness of early motion and directed exercise (EMADE) ankle rehabilitation, against usual care, i.e. 6 weeks’ immobilisation in a below-knee cast. Method/design: We have designed a pragmatic randomised controlled trial (p-RCT) to compare the EMADE intervention against usual care. We will recruit 144 independently living adult participants, absent of tissue-healing comorbidities, who have undergone surgical stabilisation of isolated Weber B ankle fractures. The EMADE intervention consists of a non-weight-bearing progressive home exercise programme, complemented with manual therapy and education. Usual care consists of immobilisation in a non-weight-bearing below-knee cast. The intervention period is between week 2 and week 6 post surgery. The primary outcome is the Olerud and Molander Ankle Score (OMAS) patient-reported outcome measure (PROM) at 12 weeks post surgery. Secondary PROMs include the EQ-5D-5 L questionnaire, return to work and return to driving, with objective outcomes including ankle range of motion. Analysis will be on an intention-to-treat basis. An economic evaluation will be included. Discussion: The EMADE intervention is a package of care designed to address the detrimental effects of disuse atrophy and joint stiffness. An advantage of the OMAS is the potential of meta-analysis with other designs. Within the economic evaluation, the cost-utility analysis, may be used by commissioners, while the use of patient-relevant outcomes, such as return to work and driving, will ensure that the study remains pertinent to patients and their families. As it is being conducted in the clinical environment, this p-RCT has high external validity. Accordingly, if significant clinical benefits and cost-effectiveness are demonstrated, EMADE should become a worthwhile treatment option. A larger-scale, multicentre trial may be required to influence national guidelines. Trial registration: ISRCTN, ID: ISRCTN11212729. Registered retrospectively on 20 March 2017

Early human impacts and ecosystem reorganization in southern-central Africa

Modern Homo sapiens engage in substantial ecosystem modification, but it is difficult to detect the origins or early consequences of these behaviors. Archaeological, geochronological, geomorphological, and paleoenvironmental data from northern Malawi document a changing relationship between forager presence, ecosystem organization, and alluvial fan formation in the Late Pleistocene. Dense concentrations of Middle Stone Age artifacts and alluvial fan systems formed after ca. 92 thousand years ago, within a paleoecological context with no analog in the preceding half-million-year record. Archaeological data and principal coordinates analysis indicate that early anthropogenic fire relaxed seasonal constraints on ignitions, influencing vegetation composition and erosion. This operated in tandem with climate-driven changes in precipitation to culminate in an ecological transition to an early, pre-agricultural anthropogenic landscape.info:eu-repo/semantics/publishedVersio

Barriers to Treatment for Female Problem Gamblers: A UK Perspective

There is a paucity of research in the UK which examines problem gambling and that which does exist is mainly quantitative, focuses on male samples and fails to look at treatment seeking populations or obstacles preventing problem gamblers from seeking treatment. This paper presents findings from part of a larger qualitative study that explored the experience of treatment for female problem gamblers. Data were collected using semi-structured interviews with eight women who had received individual cognitive-behavioural therapy in the National Health Service for their gambling problem. An interpretative phenomenological analysis approach was applied in the research process, identifying three main themes, of which the subtheme ‘Barriers to Treatment’ is examined here. Internal and external barriers to treatment organically emerged in all female participants’ accounts and appear to have an impact on service utilisation. Input directly from gamblers can be combined with findings from other studies to devise better ways of reaching female problem gamblers. A better understanding of barriers to treatment can also provide valuable direction for future research and suggest applications in clinical service provision and treatment planning

Study protocol: Comparison of different risk prediction modelling approaches for COVID-19 related death using the OpenSAFELY platform

On March 11th 2020, the World Health Organization characterised COVID-19 as a pandemic. Responses to containing the spread of the virus have relied heavily on policies involving restricting contact between people. Evolving policies regarding shielding and individual choices about restricting social contact will rely heavily on perceived risk of poor outcomes from COVID-19. In order to make informed decisions, both individual and collective, good predictive models are required.   For outcomes related to an infectious disease, the performance of any risk prediction model will depend heavily on the underlying prevalence of infection in the population of interest. Incorporating measures of how this changes over time may result in important improvements in prediction model performance.  This protocol reports details of a planned study to explore the extent to which incorporating time-varying measures of infection burden over time improves the quality of risk prediction models for COVID-19 death in a large population of adult patients in England. To achieve this aim, we will compare the performance of different modelling approaches to risk prediction, including static cohort approaches typically used in chronic disease settings and landmarking approaches incorporating time-varying measures of infection prevalence and policy change, using COVID-19 related deaths data linked to longitudinal primary care electronic health records data within the OpenSAFELY secure analytics platform.</ns4:p