Infection in osteotomy around the knee: Incidence, management and outcomes in a high-volume case series.

PURPOSE: Current evidence around the management of osteotomy-related infection is insufficient to robustly underpin the expert statements formulated by a recent European consensus statement. We present a review of a large case series in a high-volume osteotomy practice to contribute to the understanding of the incidence, management and outcome of infection in this subspecialty area. METHODS: Analyses of two prospectively collected databases for all osteotomy around the knee and infections related to osteotomy were performed, along with a review of hospital readmission data to capture all osteotomy-related infections. Clinical notes were reviewed to assess patient demographics, incidence of infection, how infection was managed and clinical outcome. RESULTS: In a series of 822 osteotomies in 755 patients, there were 21 (2.8%) cases of suspected infection. Twelve (1.6%) were contemporaneously deemed 'superficial' and nine confirmed 'deep' infections (1.2%). Deep infections were all successfully managed with wound debridement, with or without plate removal, depending on union and time from initial surgery. One of these infections was noted during a revision procedure, but no revision was carried out as a direct result of infection, no external fixation was required and no infected nonunions were experienced. CONCLUSION: All of the cases in this series were managed successfully with debridement ± removal of the plate, without the need for revision or external fixation. Any potential signs of infection around an osteotomy, especially in the case of medial high tibial osteotomy, should raise awareness for deep infection and the need for further surgery due to the limited overlying soft tissue cover. This evidence supports the recent European Society of Sports Traumatology, Knee Surgery and Arthroscopy algorithm. LEVEL OF EVIDENCE: Level IV, case series.

Lessons learnt from COVID-19 to reduce mortality and morbidity in the Global South: addressing global vaccine equity for future pandemics.

COVID-19, which killed more than 6 million people, will not be the last pandemic. Vaccines are key to preventing and ending pandemics. Therefore, it is critical to move now, before the next pandemic, towards global vaccine equity with shared goals, intermediate steps and long-term advocacy goals. Scientific integrity, ethical development, transparency, accountability and communication are critical. Countries can draw on lessons learnt from their response to the HIV pandemics, which has been at the vanguard of ensuring equitable access to rights-based services, to create shared goals and engage communities to increase access to and delivery of safe, quality vaccines. Access can be increased by: fostering the spread of mRNA intellectual property (IP) rights, with mRNA vaccine manufacturing on more continents; creating price transparency for vaccines; creating easily understandable, accessible and transparent data on vaccines; creating demand for a new international legal framework that allows IP rights to be waived quickly once a global pandemic is identified; and drawing on scientific expertise from around the world. Delivery can be improved by: creating strong public health systems that can deliver vaccines through the lifespan; creating or strengthening national regulatory agencies and independent national scientific advisory committees for vaccines; disseminating information from reliable, transparent national and subnational surveillance systems; improving global understanding that as more scientific data become available, this may result in changes to public health guidance; prioritising access to vaccines based on scientific criteria during an epidemic; and developing strategies to vaccinate those at highest risk with available vaccines.

Geriatric Assessment Is Associated With Reduced Mortality at 1 Year for Older Adults Admitted to a Major Trauma Center: A Prospective Observational Study.

OBJECTIVE: To evaluate the effect of geriatrician review on 1-year mortality in older adults admitted with trauma. BACKGROUND: Comprehensive geriatric assessment (CGA) has been associated with improved outcomes in older adults with hip fracture, but has not been evaluated in a broader trauma population. METHODS: Trauma patients aged ≥ 65years admitted to an English Major Trauma Centre between November 2018 and September 2019 were included. Patients were divided into 3 cohorts: no geriatric assessment, reactive geriatric assessment, and proactive CGA. The primary outcome was time to mortality, secondary outcomes were time to discharge and frequency of complications. Analyses were adjusted for factors known to be associated with outcomes including age, frailty, injury severity, and complications. RESULTS: Five hundred eighty-five patients were included (no geriatric assessment = 125; reactive geriatric assessment = 134; proactive CGA = 326): median age was 81 years (IQR 74-88); 326 (55.7%) were women; 297 (50.8%) were living with frailty (Clinical Frailty Scale ≥5). Median Injury Severity Score was 13 (IQR9-25). At 1-year follow-up, 147 (25.1%) patients had died. In multivariate analysis, both types of geriatric assessment were associated with reduced mortality [reactive aHR = 0.31, 95% CI 0.18-0.53; proactive adjusted hazard ratio (aHR) = 0.41, 95% CI 0.26-0.64]. There was no association between either type of geriatric assessment and length of stay (reactive aHR = 0.84, 95% CI 0.62-1.15; proactive aHR = 0.80, 95% CI 0.63-1.02). CONCLUSIONS: Geriatrician assessment is associated with reduced mortality in older adults admitted following trauma. Further research should focus on defining optimal models of geriatrician intervention.

Implementing Full Practice Authority for Advanced Practice Registered Nurses: A Case for Mitigating Critical Mental Health Services.

The COVID-19 pandemic has highlighted some perverse health disparities that we know have long existed in the United States. Disparities related to access, affordability, and cultural appropriateness of care cannot be overemphasized. More importantly, disparities related to provider shortages continue to contribute to adverse patient outcomes, particularly in rural areas and other socioeconomically deprived communities. Despite the push from the National Council of State Boards of Nursing (NCSBN) to ensure adoption and implementation of full practice authority (FPA) of advanced practice registered nurses (APRNs), currently only 28 states in the United States have achieved this goal. In addition, there are some states such as Florida that recently passed legislation supporting FPA for primary care APRNs, yet still have practice restrictions for specialty APRNs, such as mental health. The evidence is clear that patients managed by APRNs have better or comparable outcomes to those managed by physicians; thus, more advocacy is needed to ensure that all states and territories achieve this very important milestone for the profession as it has the potential to foster a collaborative interdisciplinary approach to patient care, which at the same time produces positive patient outcomes, employee satisfaction, and a work environment in which all members of the care team feel valued and autonomous.

Unmet needs in sexual health in bladder cancer patients: a systematic review of the evidence.

BACKGROUND: Bladder cancer (BC) treatment can have a detrimental effect on the sexual organs of patients and yet assessment of sexual health needs has been greatly overlooked for these patients compared to those who have undergone other cancer therapies. METHODS: This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines in July 2019. Studies were identified by conducting searches for Medline (using the PubMed interface), the Cochrane Central Register of Controlled Trials (CENTRAL) and Ovid Gateway (Embase and Ovid) using a list of defined search terms. RESULTS: 15 out of 37 studies included men only, 10 studies women only and 11 both sexes. Most participants were aged 50 to 65 years. Most studies (n = 34) focused on muscle invasive BC and only three on non-muscle invasive BC. Measurements of sexual dysfunction, including erection, ejaculation, firmness and desire, were the most commonly used measurements to report sexual health in men. In women, lubrification/dryness, desire, orgasm and dyspareunia were the most commonly reported. Twenty-one studies evaluated sexual dysfunction based on validated questionnaires, two with a non-validated questionnaire and through interviewing participants. CONCLUSION: While recognition of the importance of the inclusion of psychometric measurements to assess sexual health is growing, there is a lack of consistent measures to assess sexual health in BC. With the focus on QoL arising in cancer survivorship, further studies are needed to develop, standardize and implement use of sexual health questionnaires with appropriate psychometrics and social measures to evaluate QoL in BC patients. TRIAL REGISTRATION: "PROSPERO does not currently accept registrations for scoping reviews, literature reviews or mapping reviews. PROSPERO is therefore unable to accept your application or provide a registration number. This decision should not stop you from submitting your project for publication to a journal."

Emergency medical care of incarcerated patients: Opportunities for improvement and cost savings.

In the United States (US), the lifetime incidence of incarceration is 6.6%, exceeding that of any other nation. Compared to the general US population, incarcerated individuals are disproportionally affected by chronic health conditions, mental illness, and substance use disorders. Barriers to accessing medical care are common in correctional facilities. We sought to characterize the local incarcerated patient population and explore barriers to medical care in these patients. We conducted a retrospective, observational cohort study by reviewing the medical records of incarcerated patients presenting to the adult emergency department (ED) of a single academic, tertiary care facility with medical or psychiatric (med/psych) and trauma-related emergencies between January 2012 and December 2014. Data on demographics, medical complexity, trauma intentionality, and barriers to medical care were analyzed using descriptive statistics, unpaired student's t-test or one-way analysis of variance for continuous variables, and chi-square analysis or Fisher's exact test as appropriate. Trauma patients were younger with fewer medical comorbidities and were less likely to be admitted to the hospital than med/psych patients. 47.8% of injuries resulted from violence or were self-inflicted. Most trauma-related complaints were managed by the emergency medicine physician in the ED. While barriers to medical care were not correlated with hospital admission, 5.4% of med/psych and 2.9% of trauma patients reported barriers as a contributing factor to the ED encounter. Med/psych patients commonly reported a lack of access to medications, while trauma patients reported a delay in medical care. Trauma-related presentations were less medically complex than med/psych-related complaints. Medical management of most injuries required no hospital resources outside of the ED, indicating a potential role for outpatient management of trauma-related complaints. Additional opportunities for health care improvement and cost savings include the implementation of programs that target violence, prevent injuries, and promote the continuity of medical care while incarcerated.

Evaluation of the graded redefined assessment of strength, sensibility and prehension (GRASSP) in children with tetraplegia.

STUDY DESIGN: Psychometric study. OBJECTIVE: To validate the GRASSP in pediatric SCI populations and establish the lower age of test administration. SETTING: United States: Pennsylvania, Maryland, Illinois, Michigan, California, Texas. METHODS: Mean, SD and range of scores were calculated and examined for known-group differences. Test-retest reliability was measured by the intra-class correlation, concurrent validity of the GRASSP against the SCIM, SCIM-SS, and the CUE-Q was measured by the Spearman correlation. RESULTS: GRASSP scores differed between participants with motor complete and incomplete injuries (p = <0.0001-0.036). Test-retest reliability was strong (ICC = 0.99). Weak correlation with the total SCIM (r = 0.33-0.66), and moderate to strong correlation with the SCIM-SC (r = 37-0.70) and CUE-Q (r = 0.40-0.84). CONCLUSION: Results support the validity of the GRASSP and provide evidence that the scores are reliable when administered to children. The GRASSP sensory and strength subtests are recommended for children beginning at 6 years of age, and the GRASSP prehension performance/ability subtest for children beginning at 8 years of age. Normative data are needed for the performance components of the GRASSP.

Challenges of maintaining polio-free status of the European Region.

BACKGROUND: The European region, certified as polio free in 2002, had recent wild poliovirus (WPV) introductions, resulting in a major outbreak in Central Asian countries and Russia in 2010 and in current widespread WPV type 1 circulation in Israel, which endangered the polio-free status of the region. METHODS: We assessed the data on the major determinants of poliovirus transmission risk (population immunity, surveillance, and outbreak preparedness) and reviewed current threats and measures implemented in response to recent WPV introductions. RESULTS: Despite high regional vaccination coverage and functioning surveillance, several countries in the region are at high or intermediate risk of poliovirus transmission. Coverage remains suboptimal in some countries, subnational geographic areas, and population groups, and surveillance (acute flaccid paralysis, enterovirus, and environmental) needs further strengthening. Supplementary immunization activities, which were instrumental in the rapid interruption of WPV1 circulation in 2010, should be implemented in high-risk countries to close population immunity gaps. National polio outbreak preparedness plans need strengthening. Immunization efforts to interrupt WPV transmission in Israel should continue. CONCLUSIONS: The European region has successfully maintained its polio-free status since 2002, but numerous challenges remain. Staying polio free will require continued coordinated efforts, political commitment and financial support from all countries.

Adherence to American Diabetes Association guidelines in a volunteer-run free clinic for the uninsured: better than standards achieved by clinics for insured patients.

To determine whether Type 2 diabetes care for the uninsured is comparable to care provided to insured patients, we compared a free clinic's compliance with American Diabetes Association (ADA) clinical practice guidelines to 6 adherence evaluations in the literature. We examined diabetes management-related biomarkers, compliance with ADA-recommended health monitoring events, and presence of other health-promoting behaviors via retrospective chart review (n = 33). Results demonstrate that standards achieved by the free clinic were commensurate with, if not outperforming, published standards achieved in settings for insured patients. This evaluation emphasizes that free clinics can provide high-quality diabetes management care to patients with limited resources. This review also provides a benchmark against which results of future diabetes management interventions in both free and conventional clinic settings can be compared.

Research priorities for global measles and rubella control and eradication.

In 2010, an expert advisory panel convened by the World Health Organization to assess the feasibility of measles eradication concluded that (1) measles can and should be eradicated, (2) eradication by 2020 is feasible if measurable progress is made toward existing 2015 measles mortality reduction targets, (3) measles eradication activities should occur in the context of strengthening routine immunization services, and (4) measles eradication activities should be used to accelerate control and elimination of rubella and congenital rubella syndrome (CRS). The expert advisory panel also emphasized the critical role of research and innovation in any disease control or eradication program. In May 2011, a meeting was held to identify and prioritize research priorities to support measles and rubella/CRS control and potential eradication activities. This summary presents the questions identified by the meeting participants and their relative priority within the following categories: (1) measles epidemiology, (2) vaccine development and alternative vaccine delivery, (3) surveillance and laboratory methods, (4) immunization strategies, (5) mathematical modeling and economic analyses, and (6) rubella/CRS control and elimination.

A systematic review of the validity of dietary assessment methods in children when compared with the method of doubly labeled water.

Measuring dietary intake in children enables the assessment of nutritional adequacy of individuals and groups and can provide information about nutrients, including energy, food, and eating habits. The aim of this review was to determine which dietary assessment method(s) provide a valid and accurate estimate of energy intake by comparison with the gold standard measure, doubly labeled water (DLW). English-language articles published between 1973 and 2009 and available from common nutrition databases were retrieved. Studies were included if the subjects were children birth to age 18 years and used the DLW technique to validate reported energy intake by any other dietary assessment method. The review identified 15 cross-sectional studies, with a variety of comparative dietary assessment methods. These included a total of 664 children, with the majority having <30 participants. The majority of dietary assessment method validation studies indicated a degree of misreporting, with only eight studies identifying this to a significant level (P<0.05) compared to DLW estimated energy intake. Under-reporting by food records varied from 19% to 41% (n=5 studies) with over-reporting most often associated with 24-hour recalls (7% to 11%, n=4), diet history (9% to 14%, n=3), and food frequency questionnaires (2% to 59%, n=2). This review suggested that the 24-hour multiple pass recall conducted over at least a 3-day period that includes weekdays and weekend days and uses parents as proxy reporters is the most accurate method to estimate total energy intake in children aged 4 to 11 years, compared to total energy expenditure measured by DLW. Weighed food records provided the best estimate for younger children aged 0.5 to 4 years, whereas the diet history provided better estimates for adolescents aged≥16 years. Further research is needed in this area to substantiate findings and improve estimates of total energy expenditure in children and adolescents.

Reliability concerns in the repeated computerized assessment of attention in children.

Assessment of attentional processes via computerized assessment is frequently used to quantify intra-individual cognitive improvement or decline in response to treatment. However, assessment of intra-individual change is highly dependent on sufficient test reliability. We examined the test-retest reliability of selected variables from one popular computerized continuous performance test (CPT)-i.e., the Conners' CPT - Second Edition (CPT-II). Participants were 39 healthy children (20 girls) ages 6-18 without intellectual impairment (mean PPVT-III SS = 102.6), LD, or psychiatric disorders (DICA-IV). Test-retest reliability over the 3-8 month interval (mean = 6 months) was acceptable (Intraclass Correlations [ICC] =.82 to.92) on comparison measures (Beery Test of Visual Perception, WISC-IV Block Design, PPVT-III). In contrast, test-retest reliability was only modest for CPT-II raw scores (ICCs ranging from.62 to.82) and T-scores (ICCs ranging from.33 to.65) for variables of interest (Omissions, Commissions, Variability, Hit Reaction Time, and Attentiveness). Using test-retest reliability information published in the CPT-II manual, 90% confidence intervals based on reliable change index (RCI) methodology were constructed to examine the significance of test-retest difference/change scores. Of the participants in this sample of typically developing youth, 30% generated intra-individual changes in T-scores on the Omissions and Attentiveness variables that exceeded the 90% confidence intervals and qualified as "statistically rare" changes in score. These results suggest a considerable degree of normal variability in CPT-II test scores over extended test-retest intervals, and suggest a need for caution when interpreting test score changes in neurologically unstable clinical populations.

Comparison of two survey methodologies to assess vaccination coverage.

BACKGROUND: Measuring vaccination coverage permits evaluation and appropriate targeting of vaccination services. The cluster survey methodology developed by the World Health Organization, known as the 'Expanded Program on Immunization (EPI) methodology', has been used worldwide to assess vaccination coverage; however, the manner in which households are selected has been criticized by survey statisticians as lacking methodological rigor and introducing bias. METHODS: Thirty clusters were selected from an urban (Ambo) and a rural (Yaya-Gulelena D/Libanos) district of Ethiopia; vaccination coverage surveys were conducted using both EPI sampling and systematic random sampling (SystRS) of households. Chi-square tests were used to compare results from the two methodologies; relative feasibility of the sampling methodologies was assessed. RESULTS: Vaccination coverage from a recent measles campaign among children aged 6 months through 14 years was high: 95% in Ambo (both methodologies), 91 and 94% (SystRS and EPI sampling, respectively, P-value = 0.05) in Yaya-Gulelena D/Libanos. Coverage with routine vaccinations among children aged 12-23 months was <20% in both districts; in Ambo, EPI sampling produced consistently higher estimates of routine coverage than SystRS. Differences between the two methods were found in demographic characteristics and recent health histories. Average time required to complete a cluster was 16h for EPI sampling and 17 h for SystRS; total cost was equivalent. Interviewers reported slightly more difficulty conducting SystRS. CONCLUSIONS: Because of the methodological advantages and demonstrated feasibility, SystRS would be preferred to EPI sampling in most situations. Validating results in additional settings is recommended.

Measles supplemental immunization activities improve measles vaccine coverage and equity: Evidence from Kenya, 2002.

OBJECTIVES: To compare the measles vaccine coverage achieved through the routine vaccination program with that achieved during the 2002 supplemental immunization activity (SIA) at the national and provincial level, the percentage of previously unvaccinated children (zero-dose children) reached during the SIA, and the equity of measles vaccine coverage among children aged 9-23 months in Kenya. METHODS: Using data from a post-SIA coverage survey conducted in Kenya, we compute routine and SIA measles vaccine coverage and the percent of zero-dose children vaccinated during the SIA at the national and provincial level. Nationwide and for each province, we use the concentration index (CI) to measure equity of measles vaccine coverage. RESULTS: The SIA improved both coverage and equity, achieving significantly higher coverage in all provinces with routine measles vaccination coverage less than 80%, reached a large percentage of zero-dose children in these provinces, and reached more children belonging to the poorest households. CONCLUSION: Overall, by improving both measles vaccine coverage and equity in Kenya, the 2002 SIA reduced the gap in immunity between rich and poor households. Measles SIAs provide an ideal platform for delivering other life-saving child health interventions.