The effect of COVID-19 on a Major Trauma Network. An analysis of mechanism of injury pattern, referral load and operative case-mix.

PURPOSE: The aim of this study was to evaluate changes in both mechanism and diagnoses of injuries presenting to the orthopaedic department during this lockdown period, as well as to observe any changes in operative case-mix during this time. METHODS: A study period of twelve weeks following the introduction of the nationwide "lockdown period", March 23rd - June 14th, 2020 was identified and compared to the same time period in 2019 as a "baseline period". A retrospective analysis of all emergency orthopaedic referrals and surgical procedures performed during these time frames was undertaken. All data was collected and screened using the 'eTrauma' management platform (Open Medical, UK). The study included data from a five NHS Foundation Trusts within North West London. A total of 6695 referrals were included for analysis. RESULTS: The total number of referrals received during the lockdown period fell by 35.3% (n=2631) compared to the same period in 2019 (n=4064). Falls remained proportionally the most common mechanism of injury across all age groups in both time periods. The proportion sports related injuries compared to the overall number of injuries fell significantly during the lockdown period (p<0.001), however, the proportion of pushbike related accidents increased significantly (p<0.001). The total number of operations performed during the lockdown period fell by 38.8% (n=1046) during lockdown (n=1732). The proportion of patients undergoing operative intervention for Neck of Femur (NOF) and ankle fractures remained similar during both study periods. A more non-operative approach was seen in the management of wrist fractures, with 41.4% of injuries undergoing an operation during the lockdown period compared to 58.6% at baseline (p<0.001). CONCLUSION: In conclusion, the nationwide lockdown has led to a decrease in emergency orthopaedic referrals and procedure numbers. There has been a change in mechanism of injuries, with fewer sporting injuries, conversely, there has been an increase in the number of pushbike or scooter related injuries during the lockdown period. NOF fractures remained at similar levels to the previous year. There was a change in strategy for managing distal radius fractures with more fractures being treated non-operatively.

Efficacy assessment of co-treated alpha-ketoglutarate and N-acetyl cysteine against the subchronic toxicity of cyanide in rats.

Cyanide is an important industrial pollutant, major occupational hazard, and a potential chemical warfare agent. Its intentional or accidental exposure to humans is a big clinical problem because of its rapid mode of action. Certain plant origin foods also contain substantial amount of cyanide and cause chronic toxicity. This study explores the protective efficacy of co-treatment of alpha-ketoglutarate (AKG) and an antioxidant N-acetyl cysteine (NAC) against toxicity of subchronically exposed cyanide in rats. We explore the effect of AKG + NAC co-treatment on oxidative stress, inflammation, and histological changes induced due to long-term sublethal cyanide exposure. Cyanide induces oxidative stress by inhibiting metalloenzymes (catalase and superoxide dismutase) causing increase in lipid peroxidation (malondialdehyde) and decrease in reduced glutathione (GSH). It also increases the activity of cyclo-oxygenase enzymes causing oxidative stress-mediated inflammation in the brain. Cyanide exposure also causes degenerative changes in the brain as shown in histology. It also causes pathology in liver and kidney. AKG is known to form cyanohydrins with cyanide reducing the free cyanide levels, and its combination with NAC showed overall improvement in by reducing the oxidative stress and subsequent neuroinflammation. Their combination was also found to improve the histological outcome of vital tissues. AKG, an over-the-counter sport medicine, and the antioxidant NAC per se did not show any detrimental effects in any tested parameter. Hence, oral treatment with AKG and NAC can be beneficial for the treatment of chronic cyanide poisoning.

The cost of trauma operating theatre inefficiency.

The National Health Service (NHS) is currently facing a financial crisis with a projected deficit of £2billion by the end of financial year 2015/16. As operating rooms (OR) are one of the costliest components in secondary care, improving theatre efficiency should be at the forefront of efforts to improve health service efficiency. The objectives of this study were to characterize the causes of trauma OR delays and to estimate the cost of this inefficiency. A 1-month prospective single-centre study in St. Mary's Hospital. Turnaround time (TT) was used as the surrogate parameter to measure theatre efficiency. Factors including patient age, ASA score and presence of surgical and anaesthetic consultant were evaluated to identify positive or negative associations with theatre delays. Inefficiency cost was calculated by multiplying the time wasted with staff capacity costs and opportunity costs, found to be £24.77/minute. The commonest causes for increased TT were delays in sending for patients (50%) and problems with patient transport to the OR (31%). 461 min of delay was observed in 12 days, equivalent to loss of £951.58/theatre/day. Non-statistically significant trends were seen between length of delays and advancing patient age, ASA score and absence of either a senior clinician or an anaesthetic consultant. Interestingly, the trend was not as strong for absence of an anaesthetic consultant. This study found delays in operating TT to represent a sizable cost, with potential efficiency savings based on TT of £347,327/theatre/year. Further study of a larger sample is warranted to better evaluate the identified trends.

Country watch: India.

PIP: At the first nongovernmental organization (NGO) networking meeting on HIV/AIDS in Gujarat State, India (July 1992), the 80 participants concluded that training for grassroots volunteers was urgently needed. The Gujarat AIDS Prevention Unit (GAP-SIRMCE) assumed responsibility for organizing this capacity-building activity. GAP facilitators formulated a training-of-trainers program and outlined a workshop manual. Feedback was obtained from NGOs and experts from training programs so that a manual could be finalized. 200 NGOs were invited to participate; 65 sent delegations for training during the 1-year project. They included NGOs working on health, rural and agricultural development, family welfare, slum development, cooperative movements, and women's groups. The workshops lasted 1-3 days, generally had 10-12 participants (2 trainees per NGO). Topics included basic information on HIV/AIDS, sexuality, and barriers to condom use. There were discussions on negotiating safer sex and identifying fulfilling alternatives to sex acts. Condom demonstrations were also done. GAP then presented important educational messages. Each workshop ended with an evaluation. One of the lessons learned during the project concerned funding of participants. Some NGOs said their participation depended on money received for travel and daily subsistence. It was decided that GAP should not offer such reimbursements because this encourages NGOs to see workshop participation merely as a means of earning money. The Gujarat NGOs in the Indian Network of NGOs on HIV/AIDS have identified 2 major areas for future collaboration. The first was adolescent sex education; more than 98% of NGOs wanted to offer such programs. The second area concerned training in counseling skills in relation to HIV/AIDS and also in family planning, drug addiction, and family and marriage counseling.^ieng

Managerial gaps in the delivery of ante-natal care services in a rural area of Varanasi.

The study was conducted to identify some of the managerial gaps that affect utilization of Antenatal services. Fifty two women aged 15-39 yrs., drawn from 22 households were studied in depth. This article identifies some of the demographic and socio-cultural factors affecting utilization pattern. The degree of utilization was significantly related to education of the woman and her husband's occupation, caste, parity and cultural factors. All women lived within 1 Km from the Health Centre, did not use the services at all, thereby indicating the presence of other factors influencing their attitude towards use of services.