Variability in Fluoroscopic Image Acquisition During Operative Fixation of Ankle Fractures.

The goal of this study was to determine whether injury, level of surgeon training, and patient factors are associated with increased use of fluoroscopy during open reduction and internal fixation of ankle fractures. These relationships are not well defined. The study was a retrospective chart review of patients treated at an academic institution with primary open reduction and internal fixation of an ankle. Patient demographics, including sex, age, and body mass index, were collected, as was surgeon year of training (residency and fellowship). Image acquisition data included total number of images, total imaging time, and cumulative dose. Ankle fractures were classified according to the Weber and Lauge-Hansen classifications and the number of fixation points. Bivariate analysis and multiple regression models were used to predict increasing fluoroscopic image acquisition. Alpha was set at 0.05. Of 158 patients identified, 58 were excluded. After bivariate analysis, fracture complexity and year of training showed a significant correlation with increasing image acquisition. After multiple regression analysis, fracture complexity and year of training remained clinically significant and were independent predictors of increased image acquisition. Increasing fracture complexity resulted in 20 additional images, 16 additional seconds, and an increase in radiation of 0.7 mGy. Increasing year of training resulted in an additional 6 images and an increase of 0.35 mGy in cumulative dose. The findings suggest that protocols to educate trainee surgeons in minimizing the use of fluoroscopy would be beneficial at all levels of training and should target multiple fracture patterns.

Hanseníase e a atenção primária: desafios educacionais e assistenciais na perspectiva de médicos residentes / Leprosy and primary care: educational and health care challenges from the perspective of medical residents

A atenção primária é o nível de atenção privilegiado para ações de controle da hanseníase, doença infecciosa,negligenciada e estigmatizante, que ainda não foi controlada como problema de saúde pública no Brasil. Para descrever a percepção de médicos que atuam na atenção primária acerca da hanseníase, foi realizado um grupo focal com sete residentes de Medicina de Família e Comunidade do município de Betim, Minas Gerais. Resultados: A análise do conte-údo apontou para as subcategorias das “fontes de conhecimento”, da “assistência no nível primário” e da“educação em saúde”. Demonstrou-se uma formação para hanseníase na graduação médica foi predominantemente teórica, com poucos casos e no serviço a educação permanente foi insuficiente. Na categoria da assistência, apontou-se a exigência de um alto nível de suspeição para avaliação clínica da hanseníase,e reconheceu-se a Atenção Primária como âmbito adequado para os pacientes a despeito da demanda excessiva e estrutura física inadequada; a referência obrigatória para serviços especializados cria divisões,amplia o estigma e dificulta o acompanhamento horizontal dos pacientes com esta doença. Nas práticas educativas, percebe-se a dissociação entre a doença e sua real gravidade, fato atribuído à mudança da nomenclatura; quanto à comunicação, há necessidade de um linguajar popular, uso da mídia de massa.O estigma foi um tema transversal. Conclusão: as três categorias de análise, conhecimentos (ausentes) -assistência (insuficiente) - educação em saúde (para suspeição) se integram para explicar as dificuldades do cuidado; a graduação em medicina foi insuficiente,baseada em conteúdo teórico, poucos casos, e gera a percepção de uma doença rara, do campo de ação do sub especialista. As ações educativas devem associar o sintoma ®mancha¼ à gravidade da doença, e demanda uma Atenção Primária efetiva para atender adequadamente a estas pessoas.

Primary care is the privileged care level for measures to control leprosy, a neglected and stigmatized infectious disease that has not been controlled as a public health problem in Brazil yet. Aiming to describe the perception of leprosy by primary care physicians, we conducted a focus group with seven Family Medicine residents in the municipality of Betim, Minas Gerais. Results: Content analysis pointed to the subcategories of “knowledge sources”, “primary health care” and “health education”. Undergraduate medical training about leprosy was shown to be predominantly theoretical with few cases, and continuous education in the Local Department of Health is insufficient. In the assistance category, it was pointed out that a high level of suspicion is needed to clinically evaluate patients for leprosy. Primary healthcare was recognized as the correct treatment setting for these patients despite the excessive demands and the inadequate infrastructure of the services; the obligatory reference to specialized services creates separation, expands the stigma and complicates horizontal monitoring of the patients with this disease. In educational practices, the dissociation between the disease and severity, attributed to the change of nomenclature, is clear. Concerning communication,popular language should be used by the mass media; stigma is a crosscutting theme. Conclusion: The three categories of analysis, knowledge (absent), assistance (insufficient) and health education (for suspicion), together explain the difficulties of care. A medical degree is insufficient, relies on theoretical content with few cases, and generates the perception of a rare disease in the purview of the specialist. Educational activities must correlate the symptom of the “skin patch” to disease severity, and demand effective primary healthcare to serve these people satisfactorily.

Disability among new leprosy patients, an issue of concern: an institution based study in an endemic district for leprosy in the state of West Bengal, India.

BACKGROUND: Both magnitude and severity of disability in new leprosy patients measure indirectly the disease transmission in the community and rapidity of case detection. Various factors might be associated with the presence of impairment at registration. AIMS: To find out the prevalence of both grade 1 and grade 2 disability among new leprosy patients along with association of some clinical and sociodemographic factors. METHODS: A cross-sectional study was carried out in the Skin out patient department (OPD) of a Tertiary care hospital in West Bengal, which is situated in a highly endemic district of leprosy (prevalence was 6.5/10,000, year 2007). About 244 new leprosy patients were interviewed and clinically examined during Aug'06-Jun'07. Data was analysed in percentages, χ2 test, Anova. RESULTS: Proportion of disability was quite high among the studied new leprosy patients, 11.5% had grade-1 and 8.6% had grade-2. Disability was more among the patients with pure neuritic type of leprosy (<0.001), multibacillary leprosy (P=0.000), patients with delayed registration (P=0.000) and who were engaged as manual laborers (P=0.001). Feet were commonly involved site and nerve function impairment, both sensory and motor were the commonest nature of disability found in this study. CONCLUSION: To reduce new leprosy cases with grade-2 disability, early diagnosis of the leprosy patients and searching for grade-1 disability should be routine procedure in our health system, for which thorough neurological examination along with appropriate preventive measures is the need of the hour.

Bacterial contamination of the hands of doctors: a study in the medicine and dermatology wards.

BACKGROUND: Doctors' hands are a common source of bacterial contamination. Often, these organisms are found to be virulent species with multidrug-resistance patterns. These are the sources of nosocomial infections in many patients. AIMS: The present study was undertaken to find out the prevalence of bacterial contamination in the hands of doctors in the Medicine and Dermatology wards of a tertiary care hospital. METHODS: The hands of 44 doctors were swabbed and cultured at entry to ward and at exit. Then, tap water and alcohol swab wash techniques were used and further swabs were done at each step. Thus, each doctor was sampled four-times for the study. The antibiotic-sensitivity pattern of the organisms was determined by the disc-diffusion method. RESULTS: There was a significant contamination of the doctors' hands at entry (59.1%) and at exit (90.9%). Overall, Staphylococcus was the predominant organism (59% at entry and 85% at exit); coagulase-negative ones were more prevalent at entry (32%) and coagulase-positive ones were more prevalent at exit (54%). There was no difference in the hand contamination rates of junior and senior doctors. Also, the contamination rates were similar in the Medicine and Dermatology wards. Among the gram negative organisms, Escherichia coli (4.5%), Pseudomonas (4.5%), Enterococci (13.6%) and Klebsiella (9%) were the main ones isolated. Gram negative organisms were significantly more prevalent at exit (P = 0.009) compared with their numbers at entry. Hand washing techniques reduced the contamination rates significantly, 76% with tap water wash and further 16.5% with alcohol swab. The removal rate for both groups of organisms was similar. Also, coagulase-positive and -negative Staphylococci showed equal rates of removal with hand washing (P = 0.9793). The organisms were found to be resistant to most of the commonly used antibiotics; the beta-lactam group was especially largely resistant both for gram positive and gram negative bacteria. Both cheaper ones like cloxacillin (50-100%) and very costly ones like cefepime (100%) were equally vulnerable to resistance. Even newer antibiotics like linezolid and vancomycin showed a significant resistance to Staphylococcus. In gram negative organisms, drugs like ceftazidime and gentamicin showed 100% resistance. CONCLUSION: This study shows the high level of contamination of doctors' hands. It emphasizes the need for proper hygienic measures in day to day practice in hospitals to reduce the level of nosocomial infections. Also, it shows that most of the commonly used antibiotics will be ineffective in nosocomial infections.