Treatment outcomes of distal tibia fractures among adult patients at Moi Teaching and Referral Hospital, Eldoret, Kenya

Background: The treatment of distal tibia fractures remains challenging since they are prone to higher rates of complications. Treatment options are expanding and although their indications, advantages and disadvantages have been discussed in literature, controversy still exists over the clinical efficacy and cost-effectiveness of each option. This has led to different orthopaedic surgeons employing different operative treatment options based on their experience, preference and patient characteristics.Objective: This study sought to describe the patients’ characteristics and treatment of distal tibia fractures at MTRH and compare the outcome results of the various treatment options.Design: A prospective observational study design was used. Adult patients with distal tibia fractures admitted during the study period were included through consecutive sampling.Methods: A total of 76 patients were followed up. Data including injury aetiology, fracture types and classification, treatment and complications were collected. Functional outcome was assessed using Olerud and Molander Ankle Score (OMAS) at 6 months after treatment. Data was collected between October 2015 and March 2017 using a structured questionnaire and analyzed using STATA version 13 at 95% confidence level. Chi square test was used to determine the significance of associations between categorical variables.Results: The median age was 40.0 (30.0, 52.0) years, with a male-to-female ratio of 1.7:1. Most common causes of injury were RTA in 37 patients and falls in 29 patients. There were 48 closed and 28 open injuries. According to Arbeitsgemeinschaftfür Osteosynthesefragen (AO)/ Orthopaedic Trauma Association (OTA) classification, there were 40 (52.6%) type A, 28 (36.8%) type B and 8 (10.6%) type C fractures. Twenty-five (32.9%) patients were treated non-operatively, 28 (36.8%) patients underwent internal fixation with plating and 23 (30.3%) patients were treated using external fixation method. Non-operative treatment was mostly used for closed injuries (80%) whereas majority of open fractures (82%) were treated operatively (P=0.033). Complications occurred in 48 (57.8%) patients, including 30 (62.5%) wound infections, 21 (43.7%) malunions and 3 (6%) chronic osteomyelitis. Infections were significantly higher among external fixation treated patients (P=0.002). At final follow up the functional outcome using OMAS was excellent in 11(14.5%) patients, good in 28 (36.8%), fair in 17 (22.4%) and poor in 20 (26.3%) patients. OMAS scores were significantly high in patients treated with plating and low in patients with comminuted fractures, complications and open injuries (P<0.001).Conclusion: Distal tibia fractures mostly occurred in young males. Road traffic accidents and falls were the commonest causes. Treatment by plate fixation resulted in significantly higher functional outcome scores and lower rate of complications compared to non-operative treatment.Recommendation: Distal tibia fractures should be treated operatively by plate fixation to improve treatment outcomes.Keywords: Distal tibia fracture, OMAS, Treatment outcom

Change and continuity at PPA

This is the author accepted manuscript. The final version is available from SAGE Publications via the DOI in this record.In June 2017, Public Policy and Administration (PPA) received its first Impact Factor of 1.529 in 2016 Journal Citation Reports®. It is a fantastic score, even more so considering this has been the very first year the journal was included in the index. As a result, PPA is now ranked 19/47 in the field ‘Public Administration’! This is major change for PPA, which this year celebrates its 30th year, and bodes very well for its future. And so, we want to take this opportunity to send a strong message of continuity to our readership and all the prospective contributors. [...

Effect of atmospheric nitric oxide (NO) on measurements of exhaled NO in asthmatic children

The measurement of exhaled nitric oxide concentrations [NO] may provide a simple, noninvasive means for measuring airway inflammation. However, several measurement conditions may influence exhaled NO levels, and ambient NO may be one of these. We measured exhaled NO levels in 47 stable asthmatic children age 5 to 17 years and in 47 healthy children, gender and age matched. Exhaled [NO] in expired air was measured by a tidal breathing method with a chemiluminescence analyzer, sampling at the expiratory side of the mouthpiece. NO steady\u2010state levels were recorded. In order to keep the soft palate closed and avoid nasal contamination, the breathing circuit had a restrictor providing an expiratory pressure of 3\u20134 cm H2O at the mouthpiece. To evaluate the effect of [NO] in ambient air, measurements were randomly performed by breathing ambient air or NO\u2010free air from a closed circuit. Breathing NO\u2010free air, exhaled [NO] in asthmatics (mean \ub1 SEM) was 23.7 \ub1 1.4 ppb, significantly higher (P < 0.001) than in healthy controls (8.7 \ub1 0.4 ppb). Exhaled NO concentrations measured during ambient air breathing were higher (49 \ub1 4.6 ppb, P < 0.001) than when breathing NO\u2010free air (23.7 \ub1 1.4 ppb) and were significantly correlated (r = 0.89, P < 0.001) with atmospheric concentrations of NO (range 3\u2013430 ppb). These findings show that (1) exhaled [NO] values of asthmatic children are significantly higher than in healthy controls, and (2) atmospheric NO levels critically influence the measurement of exhaled [NO]. Therefore, using a tidal breathing method the inhalation of NO\u2010free air during the test is recommended. Pediatr Pulmonol. 1998; 26:30\u201334. \ua9 1998 Wiley\u2010Liss, Inc

Engineered membranes for residual cell trapping on microfluidic blood plasma separation systems. A comparison between porous and nanofibrous membranes

Blood-based clinical diagnostics require challenging limit-of-detection for low abundance, circulating molecules in plasma. Micro-scale blood plasma separation (BPS) has achieved remarka-ble results in terms of plasma yield or purity, but rarely achieving both at the same time. Here, we proposed the first use of electrospun polylactic-acid (PLA) membranes as filters to remove residual cell population from continuous hydrodynamic-BPS devices. The membranes hydrophilicity was improved by adopting a wet chemistry approach via surface aminolysis as demonstrated through Fourier Transform Infrared Spectroscopy and Water Contact Angle analysis. The usability of PLA-membranes was assessed through degradation measurements at extreme pH values. Plasma purity and hemolysis were evaluated on plasma samples with residual red blood cell content (1, 3, 5% hematocrit) corresponding to output from existing hydrodynamic BPS systems. Commercially available membranes for BPS were used as benchmark. Results highlighted that the electrospun membranes are suitable for downstream residual cell removal from blood, permitting the collection of up to 2 mL of pure and low-hemolyzed plasma. Fluorometric DNA quantification revealed that electrospun membranes did not significantly affect the concentration of circulating DNA. PLA-based electrospun membranes can be combined with hydrodynamic BPS in order to achieve high volume plasma separation at over 99% plasma purity

Improving pre-operative planning of robot assisted nephron sparing surgery using three-dimensional anatomical model

Introduction Despite the introduction of robot-assisted surgery in daily clinical practice, complex renal masses are still challenging even for expert surgeon. In this scenario 3D anatomical models and augmented reality represent valuable tools for the surgeon. Materials and methods We present a challenging case where PN was mandatory to preserve the overall renal function. The patient was 69 years old, with indwelling catheter for BPH and Parkinson disease. After a single episode of hematuria with negative cystoscopy, a cT1N0M0 renal cancer was diagnosed (38 mm maximum diameter). Pre-operative three-dimensional (3D) model was obtained. After multidisciplinary discussion robot-assisted partial nephrectomy was proposed. The surgery was planned according to the anatomical model. Results Before the procedure a 7Ch single loop ureteral stent was placed. The surgery was carried out in 220 minutes. Selective ischaemia was perfomed for 24 minutes. Estimated blood loss was 400cc. No post-operative complications were observed. Ureteral stent was removed 4 days after the surgery. Definitive histological examination described a pG2-3 T1a Nx R0 clear cell renal carcinoma. Conclusion In selected cases 3D model result to be a useful tool for the pre-operative planning of the surgery

Immuno-Transcriptomic Profiling of Blood and Tumor Tissue Identifies Gene Signatures Associated with Immunotherapy Response in Metastatic Bladder Cancer.

Blood-based biomarkers represent ideal candidates for the development of non-invasive immuno-oncology-based assays. However, to date, no blood biomarker has been validated to predict clinical responses to immunotherapy. In this study, we used next-generation sequencing (RNAseq) on bulk RNA extracted from whole blood and tumor samples in a pre-clinical MIBC mouse model. We aimed to identify biomarkers associated with immunotherapy response and assess the potential application of simple non-invasive blood biomarkers as a therapeutic decision-making assay compared to tissue-based biomarkers. We established that circulating immune cells and the tumor microenvironment (TME) display highly organ-specific transcriptional responses to ICIs. Interestingly, in both, a common lymphocytic activation signature can be identified associated with the efficient response to immunotherapy, including a blood-specific CD8+ T cell activation/proliferation signature which predicts the immunotherapy response

Evaluating the impact of sex-biased genetic admixture in the americas through the analysis of haplotype data

A general imbalance in the proportion of disembarked males and females in the Americas has been documented during the Trans-Atlantic Slave Trade and the Colonial Era and, although less prominent, more recently. This imbalance may have left a signature on the genomes of modern-day populations characterised by high levels of admixture. The analysis of the uniparental systems and the evaluation of continental proportion ratio of autosomal and X chromosomes revealed a general sex imbalance towards males for European and females for African and Indigenous American ancestries. However, the consistency and degree of this imbalance are variable, suggesting that other factors, such as cultural and social practices, may have played a role in shaping it. Moreover, very few investigations have evaluated the sex imbalance using haplotype data, containing more critical information than genotypes. Here, we analysed genome-wide data for more than 5000 admixed American individuals to assess the presence, direction and magnitude of sex-biased admixture in the Americas. For this purpose, we applied two haplotype-based approaches, ELAI and NNLS, and we compared them with a genotype-based method, ADMIXTURE. In doing so, besides a general agreement between methods, we unravelled that the post-colonial admixture dynamics show higher complexity than previously described

The SAFFO Study: Sex-Related Prognostic Role and Cut-Off Definition of Monocyte-to-Lymphocyte Ratio (MLR) in Metastatic Colorectal Cancer

Background: Emerging data suggest that gender-related immune system composition affects both immune response and efficacy of immunotherapy in cancer patients (pts). This study aimed to investigate the sex-related prognostic role of MLR in metastatic colorectal cancer (mCRC) pts. Methods: We analyzed a retrospective consecutive cohort of 490 mCRC patients treated from 2009 to 2018 at the Oncology Departments of Aviano and Pordenone (training set) and Udine (validation set), Italy. The prognostic impact of MLR on overall survival (OS) was evaluated with uni- and multivariable Cox regression models. The best cut-off value to predict survival was defined through ROC analyses. Results: Overall, we identified 288 males (59%) and 202 females (41%); 161 patients (33%) had a right-sided, 202 (42%) a left-sided primary, and 122 (25%) a rectal tumor. Interestingly, gender was associated with MLR (p = 0.004) and sidedness (p = 0.006). The obtained cut-off value for MLR in females and males was 0.27 and 0.49, respectively. According to univariate analysis of the training set, MLR (HR 9.07, p ≤ 0.001), MLR > 0.27 in females (HR 1.95, p = 0.003), and MLR > 0.49 in males (HR 2.65, p = 0.010) were associated with poorer OS, which was also confirmed in the validation set. In multivariate analysis, MLR > 0.27 in females (HR 2.77, p = 0.002), MLR > 0.49 in males (HR 5.39, p ≤ 0.001), BRAF mutation (HR 3.38, p ≤ 0.001), and peritoneal metastases (HR 2.50, p = 0.003) were still independently associated with worse OS. Conclusions: Males and females have a different immune response. Our study showed that high MLR, both in males and females, is an unfavorable Independent prognostic factor. Further prospective studies are needed to confirm these data

Foot Structure and Function in Habitually Barefoot and Shod Adolescents in Kenya.

Habitually barefoot (HB) children from the Kalenjin tribe of Kenya are known for their high physical activity levels. To date, there has been no comprehensive assessment of foot structure and function in these highly active and HB children/adolescents and link with overuse injuries. PURPOSE: The aim of this research is to assess foot structure, foot function, injury and physical activity levels in Kenyan children and adolescents who are HB compared with those who were habitually shod (HS). METHODS: Foot structure, function, injury prevalence, and physical activity levels were studied using two studies with equal numbers of HS and HB. HS and HB children and adolescents were matched for age, sex, and body mass. Foot arch characteristics, foot strength, and lower-limb injury prevalence were investigated in Study 1 (n = 76). Heel bone stiffness, Achilles tendon moment arm length and physical activity levels in Study 2 (n=62). Foot muscle strength was measured using a strength device TKK 3360 and heel bone stiffness by bone ultrasonometry. The moment arm length of the Achilles tendon was estimated from photographs and physical activity was assessed using questionnaires and accelerometers. RESULTS: Foot shortening strength was greater in HB (4.8 ± 1.9 kg vs 3.5 ± 1.8 kg, P < 0.01). Navicular drop was greater in HB (0.53 ± 0.32 cm vs 0.39 ± 0.19 cm, P < 0.05). Calcaneus stiffness index was greater (right 113.5 ± 17.1 vs 100.5 ± 116.8, P < 0.01 left 109.8 ± 15.7 vs 101.7 ± 18.7, P < 0.05) and Achilles tendon moment arm shorter in HB (right, 3.4 ± 0.4 vs 3.6 ± 0.4 cm, P < 0.05; left, 3.4 ± 0.5 vs 3.7 ± 0.4 cm, P < 0.01). Lower-limb injury prevalence was 8% in HB and 61% in HS. HB subjects spent more time engaged in moderate to vigorous physical activity (60 ± 26 min·d vs 31 ± 13 min·d; P < 0.001). CONCLUSIONS: Significant differences observed in foot parameters, injury prevalence and general foot health between HB and HS suggest that footwear conditions may impact on foot structure and function and general foot health. HB children and adolescents spent more time engaged in moderate to vigorous physical activity and less time sedentary than HS children and adolescents

Drug holidays and overall survival of patients with metastatic colorectal cancer

Different de-escalation strategies have been proposed to limit the risk of cumulative toxicity and guarantee quality of life during the treatment trajectory of patients with metastatic colorectal cancer (mCRC). Programmed treatment interruptions, defined as drug holidays (DHs), have been implemented in clinical practice. We evaluated the association between DHs and overall survival (OS). This was a retrospective study, conducted at the University Hospital of Udine and the IRCCS CRO of Aviano. We retrieved records of 608 consecutive patients treated for mCRC from 1 January 2005 to 15 March 2017 and evaluated the impact of different de-escalation strategies (maintenance, DHs, or both) on OS through uni-and multivariate Cox regression analyses. We also looked at attrition rates across treatment lines according to the chosen strategy. In our study, 19.24% of patients received maintenance therapy, 16.12% DHs, and 9.87% both, while 32.07% continued full-intensity first-line treatment up to progression or death. In uni-and multivariate analyses first-line continuous treatment and early discontinuation (treatment for less than 3 months) were associated to worse OS compared to non-continuous strategies (HR, 1.68; 95% CI, 1.22\u20132.32; p = 0.002 and HR,4.89; 95% CI, 3.33\u20137.19; p < 0.001, respectively). Attrition rates were 22.8%, 20.61%, and 19.64% for maintenance, DHs, or both, respectively. For continuous therapy and for treatment of less than 3 months it was 21.57% and 49%. De-escalation strategies are safe and effective options. DHs after initial induction chemotherapy may be considered in clinically selected patients with metastatic colorectal cancer