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We sought to investigate the association between hazardous alcohol use and gaps in care for people living with HIV over a long-term follow-up period. Adults who had participated in our previously published Phase I study of hazardous alcohol use at HIV programs in Kenya and Uganda were eligible at their 42 to 48 month follow-up visit. Those who re-enrolled were followed for an additional ~ 12 months. Hazardous alcohol use behavior was measured using the Alcohol Use Disorders Identification Test (AUDIT) tool. Deidentified clinical data were used to assess gaps in care (defined as failure to return to clinic within 60 days after a missed visit). The proportion of patients experiencing a gap in care at a specific time point was based on a nonparametric moment-based estimator. A semiparametric Cox proportional hazard model was used to determine the association between hazardous alcohol use at enrollment in Phase I (AUDIT score ≥ 8) and gaps in care. Of the 731 study-eligible participants from Phase I, 5.5% had died, 10.1% were lost to follow-up, 39.5% transferred, 7.5% declined/not approached, and 37.3% were enrolled. Phase II participants were older, had less hazardous drinking and had a lower WHO clinical stage than those not re-enrolled. Hazardous drinking in the re-enrolled was associated with a Hazard Ratio (HR) of 1.88 [p-value = 0.016] for a gap in care. Thus, hazardous alcohol use at baseline was associated with an increased risk of experiencing a gap in care and presents an early target for intervention.
RESUMEN: Buscamos investigar la asociación entre el uso riesgoso de alcohol y retención en programas de VIH a largo plazo. Todo adulto que participó en nuestro estudio previamente publicado sobre el uso riesgoso de alcohol en programas de VIH en Kenia y Uganda era elegible a los 42 a 48 meses de seguimiento. Los adultos reinscritos en la fueron seguidos por ~ 12 meses adicionales. Usamos el "Alcohol Use Disorders Identification Test" (AUDIT) para medir uso de alcohol. Usamos datos clínicos anonimizados para evaluar interrupciones en cuidado (definido como falta de regresar a clínica 60 días después de faltar a una cita). Basamos la proporción de pacientes con una interrupción en cuidado clínico en un estimador momentáneo y no-paramétrico. Determinamos la asociación entre el uso riesgoso de alcohol al inicio de la primera fase (puntuación AUDIT ≥8) con retención en servicios clínicos usando un modelo de riesgo Cox semiparamétrico. De los 731 participantes elegibles, 5.5% habían muerto, 10.1% fueron perdidos a seguimiento clínico, 39.5% se transfirieron a otro programa, 7.5% declinaron participación o no fueron reclutados y 37.3% fueron reinscritos en la segunda fase. Los participantes reinscritos eran mayores, tenían menos uso riesgoso de alcohol y tenían VIH menos avanzado. El uso peligroso del alcohol se vio asociado con el riesgo de tener una interrupción en cuidado clínico [Proporción de Riesgo (Hazard Ratio, HR) PR=1.88, valor-p = 0.016]. Por lo tanto, el uso peligroso del alcohol incrementa el riesgo de perder seguimiento clínico y presenta una oportunidad para intervención.
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BACKGROUND: Despite a significant burden of injury-related deaths, the Plurinational State of Bolivia (Bolivia), a lower- middle-income country in South America, lacks a formalized trauma system. This study sought to examine Bolivian trauma care from the patient perspective in order to determine barriers to care and targets for improvement. METHODS: Investigators conducted 15 semi-structured interviews with trauma patients admitted at four hospitals in Santa Cruz de la Sierra, Bolivia in June and July of 2016. Interviews were transcribed, translated, and analyzed through content and discourse analysis to identify key themes and perceptions of trauma care. RESULTS: Participants primarily presented with orthopedic injuries due to road traffic incidents and falls. Only one participant reported receiving first aid from a layperson at the scene of injury. Of the 15 participants, 12 did not know any number to contact emergency medical services (EMS). Participants expressed negative views of EMS as well as concerns for slow response times and inadequate personnel and training. Two thirds of participants were initially brought to a hospital without adequate resources to care for their injuries. Participants generally expressed positive views regarding healthcare workers involved in their hospital-based medical care. CONCLUSIONS: This region of Bolivia has a disorganized, underutilized, and distrusted trauma system. In order to increase survival, interventions should focus on improving prehospital trauma care. Potential interventions include the implementation of layperson trauma first responder courses, the establishment of a medical emergency hotline, the unification of EMS, the implementation of basic training requirements for EMS personnel, and public education campaigns to increase trust in EMS.
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Servicios Médicos de Urgencia , Bolivia/epidemiología , Primeros Auxilios , Hospitales , Humanos , Evaluación de NecesidadesRESUMEN
Addressing the burden of injury in low-resource settings requires development of trauma systems. This study aimed to describe perceptions of trauma in Santa Cruz, Bolivia to better inform strategies for trauma system development. In 2015-2016, we conducted 16 individual and 11 group interviews with key stakeholders involved with or exposed to trauma. A pile sorting activity showed participants pictures of injury mechanisms to explore perceptions of trauma. Responses were analysed for themes using content and discourse analysis. Among 27 interviews, six were with physicians, seven with first responders, three with community members, and 11 with trauma patients. Pictures commonly categorised as trauma depicted a road traffic incident (92.6%), fall (88.9%), gunshot wound (88.9%), and burn (85.2%). Fewer respondents stated intoxication (51.9%) or drowning (40.7%) were trauma. Coding of responses revealed five themes: trauma definition, mechanism, physical injury, management, and psychological trauma. Medical personnel focused more on trauma as mechanism, physical injury, and management, whereas laypersons commonly described trauma as psychological. Varied understanding of what represents trauma could influence trauma registry data collection. Laypersons' focus on psychological trauma may affect use of designated trauma care hospitals. These viewpoints must be considered when designing policies and interventions for trauma system strengthening.
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Participación de los Interesados , Heridas y Lesiones , Bolivia , Humanos , Investigación Cualitativa , Participación de los Interesados/psicología , Heridas y Lesiones/psicologíaRESUMEN
BACKGROUND: Lower extremity injuries secondary to low-energy gunshot wounds are frequently seen in the civilian populations of urban areas. Although these wounds have fewer complications than high-energy gunshot injuries, the functional and psychological damage is still significant making appropriate timely orthopaedic treatment and follow-up imperative. PURPOSE: The purpose of this study is to present our outcomes in the treatment of low-energy gunshot wounds in a civilian population at an urban, level one trauma center in patients treated by a standard protocol. METHODS: One hundred and thirty three patients who sustained 148 gunshot wound injuries were treated at our level one trauma center between January 1(st), 2009 and October 1(st), 2011. Following IRB approval, we extracted information from medical records regarding hospital course, length of stay and type of operative or non-operative treatment. If available, injury and post-operative radiographs were also reviewed. Patients were contacted by telephone to obtain Short Musculoskeletal Function Assessment (SMFA) surveys, pain on a scale of 0-10 and for the determination of any adverse events related to their shooting. RESULTS: There were 125 men (94.0%) and 8 women (6.0%) with an average age of 27.1 years (range 15.2-56.3). Seventy-six patients (57.1%) did not have any health insurance upon admission. The average length of stay in the hospital was 4.5 days (range 0.0-88.0). Fifty-one gun shots (34.5%) resulted in fractures of the lower extremities. Patients underwent a total of 95 lower extremity-related procedures during their hospitalization. Twenty-two patients (16.5%) experienced a complication related to their gunshot wounds. 38% of the cohort was available for long-term functional assessment At a mean 23.5 months (range 8-48) of follow up, patients reported mean Functional and Bothersome SMFA scores of 19.6 (SD 15.9) and 10.9 (SD 15.6) suggesting that these patients have poorer function scores than the general population. These patients still had pain related to their gunshot injury with an average pain score of 2.16 (range 0-8). CONCLUSIONS: Gunshot injuries to the extremities may involve bone, soft tissue, and neurovascular structures. Execution of appropriate therapeutic methods in such situations is critical for treating surgeons given the potential for complications. At our level one trauma center, gunshot victims were predominantly young, uninsured adult men. Complications included infection, compartment syndrome, and arterial injuries. Functional data collected demonstrated that patients continued to have difficulties with ADL's at long-term follow-up.
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Fijación de Fractura/normas , Fracturas Óseas/cirugía , Evaluación de Resultado en la Atención de Salud , Traumatismos de los Tejidos Blandos/cirugía , Heridas por Arma de Fuego/complicaciones , Heridas por Arma de Fuego/cirugía , Adolescente , Adulto , Factores de Edad , Estudios de Cohortes , Femenino , Fijación de Fractura/efectos adversos , Fijación de Fractura/métodos , Curación de Fractura/fisiología , Fracturas Óseas/etiología , Encuestas de Atención de la Salud , Humanos , Traumatismos de la Pierna/epidemiología , Traumatismos de la Pierna/etiología , Traumatismos de la Pierna/cirugía , Tiempo de Internación , Masculino , Persona de Mediana Edad , Características de la Residencia , Estudios Retrospectivos , Medición de Riesgo , Factores Sexuales , Traumatismos de los Tejidos Blandos/etiología , Centros Traumatológicos , Población Urbana , Heridas por Arma de Fuego/diagnóstico , Adulto JovenRESUMEN
INTRODUCTION: Operative fixation of displaced inferior pole patella fractures has now become the standard of care. This study aims to quantify clinical, radiographic and functional outcomes, as well as identify complications in a cohort of patients treated with non-absorbable braided suture fixation for inferior pole patellar fractures. These patients were then compared to a control group of patients treated for mid-pole fractures with K-wires or cannulated screws with tension band wiring. METHODS: In this IRB approved study, we identified a cohort of patients who were diagnosed and treated surgically for a displaced patella fracture. Demographic, injury, and surgical information were recorded. All patients were treated with a standard surgical technique utilizing non-absorbable braided suture woven through the patellar tendon and placed through drill holes to achieve reduction and fracture fixation. All patients were treated with a similar post-operative protocol and followed up at standard intervals. Data were collected concurrently at follow up visits. For purpose of comparison, we identified a control cohort with middle third patella fractures treated with either k-wires or cannulated screws and tension band technique. Patients were followed by the treating surgeon at regular follow-up intervals. Outcomes included self-reported function and knee range of motion compared to the uninjured side. RESULTS: Forty-nine patients with 49 patella fractures identified retrospectively were treated over 9 years. This cohort consisted of 31 females (63.3%) and 18 males (36.7%) with an average age of 57.1 years (range 26-88 years). Patients had an average BMI of 26.48 (range 19-44.08). Thirteen patients with inferior pole fractures underwent suture fixation and 36 patients with mid-pole fractures underwent tension band fixation (K-wire or cannulated screws with tension band). In the suture cohort, one fracture failed open repair (7.6%), which was revised again with sutures and progressed to union. Of the 36 fractures repaired with a tension band fixation, 11 underwent secondary surgery due to hardware pain or fixation failure (30.6%). At one year, no difference was seen in knee range of motion between cohorts. All fractures healed radiographically. Those patients who required reoperation or removal of hardware had significantly diminished range of motion about their injured knee (p > 0.005). CONCLUSIONS: Patients who sustain inferior pole patella fractures have limited options for fracture fixation. Suture repair is clinically acceptable, yielding similar results to patella fractures repaired with metal implants. Importantly, patients undergoing suture repair appear to have fewer hardware related postoperative complications than those receiving wire fixation for midpole fractures.
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Hilos Ortopédicos , Fijación Interna de Fracturas/instrumentación , Fracturas Óseas/cirugía , Rótula/lesiones , Suturas , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Fijación Interna de Fracturas/métodos , Curación de Fractura , Humanos , Articulación de la Rodilla/cirugía , Masculino , Persona de Mediana Edad , Rótula/cirugía , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
The purpose of this study is to describe our experience with distal femur nonunions and to report on the functional recovery of patients treated for these injuries. Twenty-two patients with an established distal femur nonunion were identified and followed prospectively. Results were compared with a control group consisting of 18 similar patients who had sustained an acute distal femur fracture. Compared with acute fracture patients, patients with a nonunion were more likely to have had an open fracture at initial injury (p = 0.02) and required a longer time to heal after final surgery (p = 0.054). No demographic variables were found to be predictive of complications, Short Musculoskeletal Functional Assessment scores, or time to union. These results show that patients with a distal femoral nonunion can expect to attain similar ultimate outcomes to patients receiving treatment for an acute distal femur fracture. Unlike the development of nonunions following other types of fracture, such as the hip, distal femur nonunions do not portend poor functional outcomes as long as bone union is achieved.
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Fracturas del Fémur/cirugía , Fracturas no Consolidadas/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Fracturas del Fémur/diagnóstico por imagen , Fracturas no Consolidadas/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Radiografía , Recuperación de la Función , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Bilateral ruptures of the extensor mechanism are rare. QUESTIONS/PURPOSE: The purpose of this study was to compare the clinical outcomes of operatively treated unilateral and bilateral knee soft tissue extensor mechanism injuries and to identify risk factors for bilateral disruption. METHODS: All patients operatively treated for a knee extensor mechanism injury were entered into a database and prospectively followed. Postoperative protocol was standardized for all patients. Demographic data, baseline characteristics, range of motion, complications, pain, and functional status were assessed. The main patient-reported outcome measures used in this study were the SF-36 Health Survey and the Lysholm Scale. RESULTS: Patients who sustained bilateral injuries were more likely to have one or more systemic medical conditions. There was no statistical difference between the groups with regard to mechanism of injury or body mass index. The average follow-up was 29 months (range 6-60 months). Patient-reported outcomes, in the form of the SF-36 Health Survey and Lysholm scores, were not significantly different between the two groups at final follow-up. Range of motion and quadriceps strength was also similar between the two cohorts. At latest follow-up, 88% of patients with unilateral injuries and 83% of patients with bilateral disruption were able to return to their pre-injury employment. CONCLUSION: Operatively treated bilateral knee extensor mechanism disruptions fare similar to unilateral injuries with regard to ultimate functional outcome. The presence of one of more preexisting medical conditions was identified as a risk factor for bilateral tendinous disruption.
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OBJECTIVES: Recombinant human parathyroid hormone (PTH 1-34) has been previously shown to enhance fracture healing in animal models. Here, we sought to determine whether the systemic administration of PTH 1-34 is effective in preventing atrophic fracture nonunion in a murine, surgical nonunion model. METHODS: We used an established reproducible long-bone murine fracture nonunion model by generating a midshaft femur fracture, followed by fracture distraction using an intramedullary pin and custom metallic clip to maintain a fracture gap of 1.7 mm. Mice were randomized to receive either daily intraperitoneal injections of 30 µg/kg PTH 1-34 for 14 days or saline injections. At 6 weeks after the procedure, radiographic and histologic assessment of fracture healing was performed. RESULTS: At 6 weeks after surgery, the group treated with PTH showed higher rates of bony union (50% vs 8%; P < 0.05) as assessed by radiographic analysis. Mean gap size was also significantly lower in the PTH group (1.42 vs 0.36 mm in the control group; P < 0.05). Histologic analysis of atrophic nonunions in the control group revealed a persistent fracture gap with intervening fibrous tissue. In contrast, healed subjects in the PTH-treated group had cortical bridging with mature bone and relatively little callus, which is consistent with primary intramembranous ossification. CONCLUSIONS: Daily systemic administration of recombinant PTH 1-34 increased the rate of union in a mouse atrophic nonunion model. This may have important implications for the potential clinical role of PTH 1-34 in the treatment of atrophic fracture nonunions.
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Modelos Animales de Enfermedad , Fracturas del Fémur/tratamiento farmacológico , Fracturas del Fémur/patología , Curación de Fractura/efectos de los fármacos , Fracturas Mal Unidas/tratamiento farmacológico , Fracturas Mal Unidas/patología , Fragmentos de Péptidos/administración & dosificación , Teriparatido/análogos & derivados , Animales , Humanos , Inyecciones Intraperitoneales , Ratones , Ratones Endogámicos C57BL , Teriparatido/administración & dosificación , Resultado del TratamientoRESUMEN
Sympathomimetic drugs (MDMA; ecstasy) induce a potentially catastrophic hyperthermia that involves free fatty acid (FFA) activation of mitochondrial uncoupling proteins (UCP). Insulin is an important regulator of plasma FFA levels, although its role in thermogenesis is unclear. The aims of the present study were 1) to characterize the pharmacodynamic effects of MDMA on plasma insulin and glucose, 2) to examine the effects of insulin on MDMA-induced thermogenesis and 3) to examine MDMA-induced thermogenesis in an animal model of insulin resistance, the obese Zucker rat. Insulin levels peaked 15 min after MDMA (40 mg/kg, s.c.), which preceded the peak temperature change at 60 min. Plasma glucose levels also peaked 15 min. after MDMA and remained elevated throughout the 90-min. monitoring period. Insulin pretreatment (10 units/kg, s.c.) 30 min. before a low dose of MDMA (5 mg/kg, s.c.) potentiated the thermogenic response. Insulin resistant, fa/fa (obese) Zucker rats demonstrated an attenuated thermogenic response to MDMA (40 mg/kg, s.c.). Consistent with the role for FFA in UCP3 expression, immunoblot analysis showed significantly increased levels of UCP3 protein obese compared to lean Zucker skeletal muscle. In conclusion, the results of the present study suggest a potential role of insulin signaling in sympathomimetic-induced thermogenesis.