The management of segmental tibial shaft fractures: A systematic review.

INTRODUCTION: Segmental tibial fractures are complex injuries associated with significant soft tissue damage that are difficult to treat. This study aimed to identify the most effective method of treating segmental tibial fractures. METHOD: A PRISMA compliant systematic review was conducted. Studies investigating the management of segmental tibial fractures with intramedullary nail fixation (IMN), open reduction and internal fixation (ORIF) or circular external fixation (CEF) were included for review. The primary outcome measure was time to fracture union. Secondary outcomes were complications and functional outcome. A narrative analysis was undertaken as meta-analysis was inappropriate due to heterogeneity of the data. RESULTS: Thirteen studies were eligible and included. No randomised controlled trials were identified. Fixation with an intramedullary nail provided the fastest time to union, followed by open reduction and internal fixation and then CEF. The rate of deep infection was highest after IMN (5/162 [3%]), followed by open reduction and internal fixation (2/78 [2.5%]) and CEF (1/54 [2%]). However, some studies reported particularly high rates of infection following IMN for open segmental tibial fractures. There was limited reporting of postoperative deformities. From the studies that did include such data, there was a higher rate of deformity following ORIF (8/53 [15%]), compared to IMN (13/138 [9%]), and CEF (4/44 [9%]). Three studies, not including IMN, described patient reported outcome measures with results ranging from 'excellent' to 'fair'. DISCUSSION: The available evidence was of poor quality, dominated by retrospective case series. This prevented statistical analysis, and precludes firm conclusions being drawn from the results available. CONCLUSION: IMN has the fastest time to fracture union, however there are concerns regarding an increased deep infection rate in open segmental tibial fractures. In this subgroup, the data suggests CEF provides the most satisfactory results. However, the available literature does not provide sufficient detail to make this statement with certainty. We recommend a randomised controlled study to further investigate this challenging problem

Using mHealth to improve health care delivery in India: A qualitative examination of the perspectives of community health workers and beneficiaries.

BACKGROUND:mHealth technologies are proliferating globally to address quality and timeliness of health care delivery by Community Health Workers (CHWs). This study aimed to examine CHW and beneficiaries' perceptions of a new mHealth intervention (Common Application Software [CAS] for CHWs in India. The objectives of the study were to seek perspectives of CHWs and beneficiaries on the uptake of CAS, changes in CHW-beneficiary interactions since the introduction of CAS and potential barriers faced by CHWs in use of CAS. Further, important contextual factors related to CHW-beneficiary interface and dynamics that may have a bearing on CAS have been described. METHODS:A qualitative study was conducted in two states of India (Bihar and Madhya Pradesh) from March-April 2018 with CHWs (n = 32) and beneficiaries (n = 55). All interviews were conducted and recorded in Hindi, transcribed and translated into English, and coded and thematically analysed using Dedoose. FINDINGS:The mHealth intervention was acceptable to the CHWs who felt that CAS improved their status in the communities where they worked. Beneficiaries' views were a mix of positive and negative perceptions. The divergent views between CHWs and beneficiaries surrounding the use and impact of CAS highlight an underlying mistrust, socio-cultural barriers in engagement, and technological barriers in implementation. All these contextual factors can influence the perception and uptake of CAS. CONCLUSIONS:mHealth interventions targeting CHWs and beneficiaries have the potential to improve performance of CHWs, reduce barriers to information and potentially change the behaviors of beneficiaries. While technology is an enabler for CHWs to improve their service delivery, it does not necessarily help overcome social and cultural barriers that impede CHW-beneficiary interactions to bring about improvements in knowledge and health behaviors. Future interventions for CHWs including mHealth interventions should examine contextual factors along with the acceptability, accessibility, and usability by beneficiaries and community members

A bibliometric analysis assessing temporal changes in publication and authorship characteristics in The Knee from 1996 to 2016.

BACKGROUND: Evidence-based practice is a foundation to clinical excellence. However there remains little evidence on the characteristics of authors who contribute to the evidence-base and whether these have changed over time. The purpose of this study was to explore these characteristics by undertaking a bibliometric analysis to explore publication and authorship characteristics in a leading sub-speciality orthopaedic journal (The Knee) over a 20-year period. METHODS: All articles published in The Knee in 1996, 2006 and 2016 were identified. For each article, data collected included: highest academic award; profession; gender; continent of first and last author; total number of authors; the level of evidence; and funding source. We analysed temporal changes in these variables using appropriate statistical models. RESULTS: A total of 413 papers were analysed. Between 1996 to 2016 there has been a significant increase in the overall number of authors, the number of paper submitted from Asia, the proportion of Level 1 or 2 tiered evidence, the proportion of people with Bachelor or Master-level degrees as their highest level of educational award and the proportion of non-medically qualified authors (P<0.001). From 2006 to 2016 there was a significant increase in the proportion of articles whose first author was female (P=0.03), but no significant change in the number of females as last author (P=0.43). CONCLUSION: The findings indicate that there have been changes in publication and authorship characteristics in this sub-speciality orthopaedic journal during the past 20years. This provides encouraging indication of greater diversification and internationalisation of orthopaedic research

Paying More for the American Dream III: Promoting Responsible Lending to Lower-Income Communities and Communities of Color

This report analyzes 2007 Home Mortgage Disclosure Act data and finds that, in low- and moderate-income communities, depositories with CRA obligations originate a far smaller share of higher-cost loans than lenders not subject to CRA. It also finds that lenders covered by CRA are much less likely to make higher-cost loans in communities of color than lenders not covered by CRA

The effect of targeted treatment on people with patellofemoral pain: A pragmatic, randomised controlled feasibility study

Background: Targeted treatment, matched according to specific clinical criteria e.g. hip muscle weakness, may result in better outcomes for people with patellofemoral pain (PFP). However, to ensure the success of future trials, a number of questions on the feasibility of a targeted treatment need clarification. The aim of the study was to explore the feasibility of matched treatment (MT) compared to usual care (UC) management for a subgroup of people with PFP determined to have hip weakness and to explore the mechanism of effect for hip strengthening. Methods: In a pragmatic, randomised controlled feasibility study, 24 participants with PFP (58% female; mean age 29 years) were randomly allocated to receive either MT aimed specifically at hip strengthening, or UC over an eight-week period. The primary outcomes were feasibility outcomes, which included rates of adherence, attrition, eligibility, missing data and treatment efficacy. Secondary outcomes focused on the mechanistic outcomes of the intervention, which included hip kinematics. Results: Conversion to consent (100%), missing data (0%), attrition rate (8%) and adherence to both treatment and appointments ( > 90%) were deemed successful endpoints. The analysis of treatment efficacy showed that the MT group reported a greater improvement for the Global Rating of Change Scale (62% vs. 9%) and the Anterior Knee Pain Scale (-5.23 vs. 1.18) but no between-group differences for either average or worst pain. Mechanistic outcomes showed a greatest reduction in peak hip internal rotation angle for the MT group (13.1% vs. -2.7%). Conclusion: This feasibility study indicates that a definitive randomised controlled trial investigating a targeted treatment approach is achievable. Findings suggest the mechanism of effect of hip strengthening may be to influence kinematic changes in hip function in the transverse plane

"El nen s'ha menjat una aranya": The development of narratives in Catalan speaking children

The production of a well-constructed narrative is the culmination of several years of language acquisition and is an important milestone in children's development. There is no current description of narrative development for Catalan speaking children. This study collected elicited narratives in Catalan from 118 children aged 4;0-10;11. Narratives were scored for macrostructure and microstructure. Narrative scores improved with age with maximum performance for macrostructure by 9 years. Children's ability to use micro-structural components of Catalan is variable with some developments continuing beyond 9 years. The results are discussed in relation to theoretical arguments about universal and specific features of narrative development. We conclude by highlighting the usefulness of the new test for future language assessment of children acquiring Catalan

Heat stress incident prevalence and tennis matchplay performance at the Australian Open

© 2017 Sports Medicine Australia Objectives: To examine the association of wet bulb globe temperature (WBGT) with the occurrence of heat-related incidents and changes in behavioural and matchplay characteristics in men's Grand Slam tennis. Design: On-court calls for trainers, doctors, cooling devices and water, post-match medical consults and matchplay characteristic data were collected from 360 Australian Open matches (first 4 rounds 2014–2016). Methods: Data were referenced against estimated WBGT and categorised into standard zones. Generalised linear models assessed the association of WBGT zone on heat-related medical incidences and matchplay variables. Results: On-court calls for doctor (47% increase per zone, p = 0.001), heat-related events (41%, p = 0.019), cooling devices (53%, p 32 °C and >28 °C, significant increases in heat-related calls (p = 0.019) and calls for cooling devices (p 32 °C) and cooling device callouts (>28 °C). However, few matchplay characteristics were noticeably affected, with only reduced net approaches and increased aces evident in higher estimated WBGT environments

Does physical activity change following hip and knee replacement? Matched case-control study evaluating Physical Activity Scale for the Elderly data from the Osteoarthritis Initiative

Objectives: To determine whether physical activity measured using the Physical Activity Scale for the Elderly (PASE), changes during the initial 24 months post-total hip (THR) or knee replacement (TKR), and how this compares to a matched non-arthroplasty cohort. Design: Case-controlled study analysis of a prospectively collected dataset. Setting: USA community-based. Participants: 116 people post-THR, 105 people post-TKR compared to 663 people who had not undergone THR or TKR, or had hip or knee osteoarthritis. Cohorts were age-, gender- and BMI-matched. Main outcome measures: Physical activity assessed using the 12-item PASE at 12 and 24 months post-operatively. Results: There was no significant difference in total PASE score between pre-operative to 12 months (mean: 136 vs. 135 points; p=0.86) or 24 months following THR (mean: 136 vs 132 points; p=0.95). Whilst there was no significant difference in total PASE score from pre-operative to 12 months post-TKR (126 vs. 121 points; p=0.93), by 24 months people following TKR reported significantly greater physical activity (126 vs. 142 points; p=0.04). There was no statistically significant difference in physical activity between the normative matched and THR (p≥0.14) or TKR (p≥0.06) cohorts at 12 or 24 months post-joint replacement. Conclusions: Physical activity is not appreciably different to pre-operative levels at 12 or 24 months post-THR, but was greater at 24 months following TKR. Health promotion strategies are needed to encourage greater physical activity participation following joint replacement, and particularly targeting those who undergo THR

The feasibility of a randomised control trial to assess physiotherapy against surgery for recurrent patellar instability

Background: Patellar instability is a relatively common condition that leads to disability and restriction of activities. People with recurrent instability may be given the option of physiotherapy or surgery though this is largely driven by clinician preference rather than by a strong evidence base. We sought to determine the feasibility of conducting a definitive trial comparing physiotherapy with surgical treatment for people with recurrent patellar instability. Methods: This was a pragmatic, open-label, two-arm feasibility randomised control trial (RCT) with an embedded interview component recruiting across three NHS sites comparing surgical treatment to a package of best conservative care; 'Personalised Knee Therapy' (PKT). The primary feasibility outcome was the recruitment rate per centre (expected rate 1 to 1.5 participants recruited each month). Secondary outcomes included the rate of follow-up (over 80% expected at 12 months) and a series of participant-reported outcomes taken at 3, 6 and 12 months following randomisation, including the Norwich Patellar Instability Score (NPIS), the Kujala Patellofemoral Disorder Score (KPDS), EuroQol-5D-5L, self-reported global assessment of change, satisfaction at each time point and resources use. Results: We recruited 19 participants. Of these, 18 participants (95%) were followed-up at 12 months and 1 (5%) withdrew. One centre recruited at just over one case per month, one centre was unable to recruit, and one centre recruited at over one case per month after a change in participant screening approach. Ten participants were allocated into the PKT arm, with nine to the surgical arm. Mean Norwich Patellar Instability Score improved from 40.6 (standard deviation 22.1) to 28.2 (SD 25.4) from baseline to 12 months. Conclusion: This feasibility trial identified a number of challenges and required a series of changes to ensure adequate recruitment and follow-up. These changes helped achieve a sufficient recruitment and follow-up rate. The revised trial design is feasible to be conducted as a definitive trial to answer this important clinical question for people with chronic patellar instability. Trial registration: The trial was prospectively registered on the International Standard Randomised Controlled Trial Number registry on the 22/12/2016 (reference number: ISRCTN14950321). http://www.isrctn.com/ISRCTN1495032