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

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

Acute and chronic kidney disease in elderly patients with hip fracture: prevalence, risk factors and outcome with development and validation of a risk prediction model for acute kidney injury

Background Hip fracture is a common injury in older people with a high rate of postoperative morbidity and mortality. This patient group is also at high risk of acute kidney injury (AKI) and chronic kidney disease (CKD), but little is known of the impact of kidney disease on outcome following hip fracture. Methods An observational cohort of consecutive patients with hip fracture in a large UK secondary care hospital. Predictive modelling of outcomes using development and validation datasets. Inclusion: all patients admitted with hip fracture with sufficient serum creatinine measurements to define acute kidney injury. Main outcome measures – development of acute kidney injury during admission; mortality (in hospital, 30-365 day and to follow-up); length of hospital stay. Results Data were available for 2848 / 2959 consecutive admissions from 2007-2011; 776 (27.2%) male. Acute kidney injury occurs in 24%; development of acute kidney injury is independently associated with male sex (OR 1.48 (1.21 to 1.80), premorbid chronic kidney disease stage 3B or worse (OR 1.52 (1.19 to 1.93)), age (OR 3.4 (2.29 to 5.2) for >85 years) and greater than one major co-morbidities (OR 1.61 (1.34 to 1.93)). Acute kidney injury of any stage is associated with an increased hazard of death, and increased length of stay (Acute kidney injury: 19.1 (IQR 13 to 31) days; no acute kidney injury 15 (11 to 23) days). A simplified predictive model containing Age, CKD stage (3B-5), two or more comorbidities, and male sex had an area under the ROC curve of 0.63 (0.60 to 0.67). Conclusions Acute kidney injury following hip fracture is common and associated with worse outcome and greater hospital length of stay. With the number of people experiencing hip fracture predicted to rise, recognition of risk factors and optimal perioperative management of acute kidney injury will become even more important

Gendered Risk Perceptions Associated with Human-Wildlife Conflict: Implications for Participatory Conservation

This research aims to foster discourse about the extent to which gender is important to consider within the context of participatory approaches for biological conservation. Our objectives are to: (1) gender-disaggregate data about stakeholders' risk perceptions associated with human-wildlife conflict (HWC) in a participatory conservation context, and (2) highlight insights from characterizing gendered similarities and differences in the way people think about HWC-related risks. Two communal conservancies in Caprivi, Namibia served as case study sites. We analyzed data from focus groups (n = 2) to create gendered concept maps about risks to wildlife and livelihoods and any associations of those risks with HWC, and semi-structured interviews (n = 76; men = 38, women = 38) to measure explicit risk attitudes associated with HWC. Concept maps indicated some divergent perceptions in how groups characterized risks to wildlife and livelihoods; however, not only were identified risks to wildlife (e.g., pollution, hunting) dissimilar in some instances, descriptions of risks varied as well. Study groups reported similar risk perceptions associated with HWC with the exception of worry associated with HWC effects on local livelihoods. Gendered differences in risk perceptions may signal different priorities or incentives to participate in efforts to resolve HWC-related risks. Thus, although shared goals and interests may seem to be an obvious reason for cooperative wildlife management, it is not always obvious that management goals are shared. Opportunity exists to move beyond thinking about gender as an explanatory variable for understanding how different groups think about participating in conservation activities