Assessing the Effectiveness of a Multicomponent Intervention on Hand Hygiene and Well-Being in Primary Health Care Centers and Schools Lacking Functional Water Supply in Protracted Conflict Settings: Protocol for a Cluster Randomized Controlled Trial.

BACKGROUND: Hand hygiene is crucial in health care centers and schools to avoid disease transmission. Currently, little is known about hand hygiene in such facilities in protracted conflict settings. OBJECTIVE: This protocol aims to assess the effectiveness of a multicomponent hand hygiene intervention on handwashing behavior, underlying behavioral factors, and the well-being of health care workers and students. Moreover, we report our methodology and statistical analysis plan transparently. METHODS: This is a cluster randomized controlled trial with 2 parallel arms taking place in 4 countries for 1 year. In Burkina Faso and Mali, we worked in 24 primary health care centers per country, whereas in Nigeria and Palestine, we focused on 26 primary schools per country. Facilities were eligible if they were not connected to a functioning water source but were deemed accessible to the implementation partners. Moreover, health care centers were eligible if they had a maternity ward and ≥5 employees, and schools if they had ≤7000 students studying in grades 5 to 7. We used covariate-constrained randomization to assign intervention facilities that received a hardware, management and monitoring support, and behavior change. Control facilities will receive the same or improved intervention after endline data collection. To evaluate the intervention, at baseline and endline, we used a self-reported survey, structured handwashing observations, and hand-rinse samples. At follow-up, hand-rinse samples were dropped. Starting from the intervention implementation, we collected longitudinal data on hygiene-related health conditions and absenteeism. We also collected qualitative data with focus group discussions and interviews. Data were analyzed descriptively and with random effect regression models with the random effect at a cluster level. The primary outcome for health centers is the handwashing rate, defined as the number of times health care workers performed good handwashing practice with soap or alcohol-based handrub at one of the World Health Organization 5 moments for hand hygiene, divided by the number of moments for hand hygiene that presented themselves during the patient interaction within an hour of observation. For schools, the primary outcome is the number of students who washed their hands before eating. RESULTS: The baseline data collection across all countries lasted from February to June 2023. We collected data from 135 and 174 health care workers in Burkina Faso and Mali, respectively. In Nigeria, we collected data from 1300 students and in Palestine from 1127 students. The endline data collection began in February 2024. CONCLUSIONS: This is one of the first studies investigating hand hygiene in primary health care centers and schools in protracted conflict settings. With our strong study design, we expect to support local policy makers and humanitarian organizations in developing sustainable agendas for hygiene promotion. TRIAL REGISTRATION: ClinicalTrials.gov NCT05946980 (Burkina Faso and Mali); https://www.clinicaltrials.gov/study/NCT05946980 and NCT05964478 (Nigeria and Palestine); https://www.clinicaltrials.gov/study/NCT05964478. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/52959.

Poor midterm clinical outcomes and a high percentage of unsatisfying results are reported after seizure-related shoulder injuries, especially after posterior proximal humerus fracture-dislocations.

BACKGROUND: Treating seizure-related shoulder injuries is challenging, and an evidence-based consensus to guide clinicians is lacking. The aim of this prospective single-center observational clinical trial was to evaluate the clinical results of a cohort of patients undergoing treatment of seizure-related shoulder injuries, to categorize them according to the lesion's characteristics, with special focus on patients with proximal humerus fracture-dislocations (PHFDs), and to define groups at risk of obtaining unsatisfactory results. We hypothesized that patients with a PHFD, considered the worst-case scenario among these injuries, would report worse clinical results in terms of the quick Disabilities of the Arm, Shoulder, and Hand questionnaire (qDASH) as compared to the other patients. METHODS: Patients referred to a tertiary epilepsy center who have seizure-related shoulder injuries and with a minimum follow-up of 1 year were included. A quality-of-life assessment instrument (EQ-5D-5L), a district-specific patient-reported outcome measure (qDASH), and a pain assessment tool (visual analog scale [VAS]) were used for the clinical outcome evaluation. Subjective satisfaction and fear of new shoulder injuries was also documented. Categorization and subgroup analysis according to the presence and features of selected specific lesions were performed. RESULTS: A total of 111 patients were deemed eligible and 83 were available for follow-up (median age 38 years, 30% females), accounting for a total of 107 injured shoulders. After a median follow-up of 3.9 (1.6-8.2) years, overall moderate clinical results were reported. In addition, 34.1% of the patients reported a VAS score ≥35 mm, indicating moderate to severe pain, and 34.1% a qDASH score ≥40 points, indicating severe disability of an upper limb. These percentages rose to, respectively, 45.5% and 48.5% in the subgroup of patients with PHFDs and to 68.8% and 68.8% in patients experiencing posterior PHFD. Overall, 46.9% of the patients considered themselves unsatisfied with the treatment and 62.5% reported a persistent fear of a new shoulder injury. CONCLUSIONS: Patients with seizure-related shoulder injuries reported only moderate clinical results at their midterm follow-up. Older age, male sex, and absence or discontinuation of antiepileptic drug (AED) treatment were identified as characterizing features of patients with posterior dislocation episodes. In patients with PHFD, a tendency to worse clinical results was observed, with posterior PHFD patients emerging as a definite subgroup at risk of reporting unsatisfying results after treatment.

Epidemiology and specific features of shoulder injuries in patients affected by epileptic seizures.

PURPOSE: Epileptic seizures can cause multiple shoulder injuries, the most common of which are dislocations, recurrent instability, fractures, and isolated lesions of the rotator cuff. Currently, only limited literature exists which describes the frequency and types of lesions in cohorts of epileptic patients and the corresponding treatment outcome. This study aims to document the occurrence of shoulder lesions in patients affected by seizures and to provide detailed information on trauma dynamics, specific lesion characteristics and treatment complications. METHODS: All patients referring to a tertiary epilepsy center were screened for shoulder injuries and the clinical records of those sustaining them during a seizure were reviewed. Demographic information, lesions' characteristics and trauma dynamics were analysed, as wells as-when carried out-the type of surgical intervention and any postoperative complications. RESULTS: The average age at the time of injury of 106 included patients was 39.7 ± 17.5 years and a male predominance was recorded (65%). Bilateral injuries occurred in 29 patients, simultaneously in 17 cases. A younger age, bilateral shoulder injuries and shoulder dislocations were significantly associated with the occurrence of a shoulder injury solely by muscular activation (p = 0.0054, p = 0.011, p < 0.0001). The complication rate in 57 surgically treated patients with follow-up data was 38.7%, with recurring instability being the most frequently reported complication (62.5%). CONCLUSIONS: Uncontrolled muscle activation during a seizure is a distinctive but not exclusive dynamic of injury in epileptic patients, accounting for more than the half of all shoulder lesions, especially in the younger. This can lead both to anterior and posterior dislocations or fracture-dislocations and is frequently cause of bilateral lesions and of instability recurrence after surgery. The high complication rates after surgical treatment in this selected subgroup of patients require that appropriate preventative measures are taken to increase the probability of treatment success. LEVEL OF EVIDENCE: Cohort study, level III.

Treatment of partial rotator cuff lesions is associated with a higher frequency of post-operative shoulder stiffness. A prospective investigation on the role of surgery-related risk factors for this complication.

PURPOSE: Post-operative shoulder stiffness (SS) is a common complication after arthroscopic rotator cuff (RC) repair. The aim of this prospective study is to evaluate the role of surgical risk factors in the development of this complication, with special focus on the characteristics of the RC tears. METHODS: Two-hundred and twenty patients who underwent arthroscopic RC repair for degenerative posterosuperior RC tears were included. Surgery-related risk factors for development of post-operative SS belonging to the following five categories were documented and analyzed: previous surgery, RC tear characteristics, hardware and repair type, concomitant procedures, time and duration of surgery. The incidence of post-operative SS was evaluated according to the criteria described by Brislin and colleagues. RESULTS: The incidence of post-operative SS was 8.64%. The treatment of partial lesions by tear completion and repair technique was significantly associated with development of post-operative SS (p = 0.0083, pc = 0.04). A multivariate analysis revealed that treatment of partial lesions in patients younger than 60 years was associated to a higher risk of developing post-operative SS (p = 0.007). Previously known pre-operative risk factors such as female sex and younger age were confirmed. No other significant associations were documented. CONCLUSION: The treatment of partial lesions of the RC may lead to a higher risk of post-operative SS than the treatment of complete lesions, in particular in patients younger than 60 years. Possible explanations of this finding are the increased release of pro-inflammatory cytokines caused by the additional surgical trauma needed to complete the lesion and the different pain perception of the subgroup of patients who require surgical treatment already for partial tears. EVIDENCE: A higher risk of post-operative SS should be expected after tear completion and repair of partial lesions, especially in young patients. Appropriate pre-operative counseling and post-operative rehabilitation should be considered when approaching this subgroup of RC tears. LEVEL OF EVIDENCE: Prognostic study, level II.

Gamifying quantitative face-to-face interviews in rural India: An empirical evaluation based on the basic psychological needs theory.

OBJECTIVE: Standardized face-to-face interviews are widely used in low and middle-income countries to collect data for social science and health research. Such interviews can be long and tedious. In an attempt to improve the respondents' experience of interviews, we developed a concept of gamified interview format by including a game element. Gamification is reported to increase engagement in tasks, but results from rigorously developed research are equivocal, and a theory of gamification is still needed. MATERIALS & METHODS: We evaluated the proposed gamification with a randomized controlled trial based on self-determination theory, specifically on the basic psychological needs theory. In total, 1266 respondents were interviewed. Single and multiple mediation analyses were used to understand the effects of the gamified interview format. RESULTS: Our evaluation showed that the gamification we had developed did not improve the outcome, the experience of the interview reported by respondent. The effect of the gamified interview format depended on the ability of respondents: gamification can be counterproductive if it overburdens the respondents. However, the basic psychological needs theory explained the mechanisms of action of gamification well: feeling competent and related to others improved the reported experience of the interview. CONCLUSION: We emphasize the need to develop context-specific gamification and invite researchers to conduct equivalently rigorous evaluations of gamification in future studies.

Basic Clinical Examination of the Foot and Ankle. / Klinische Basisuntersuchungen am Fuß und Sprunggelenk.

Successful treatment of foot and ankle diseases requires an accurate diagnosis. In addition to differentiated history taking, clinical examination is the most important component in the diagnosis of foot and ankle diseases. The present video explains the common provocation tests and functional tests that are used in the basic clinical examination of the foot and ankle complex. In addition to general inspection and palpation, the focus is on different diagnostic tests and clinical signs that improve diagnostic accuracy. The present basic clinical examination methods allow a structured approach to clinical issues and can be a good basis, if supplemented by further specific and individual tests.

Increasing latrine use in rural Karnataka, India using the risks, attitudes, norms, abilities, and self-regulation approach: A cluster-randomized controlled trial.

Recent years have seen unparalleled efforts by the Swatchh Bharat Mission (SBM) to make India open defecation free. While latrine coverage has been boosted very successfully, latrine use has remained low in many areas of the country. Consequently, the aim of this study was to use robust psychological theory to develop and rigorously evaluate low-cost and scalable behaviour change interventions to promote latrine use in rural India. This study reports findings from a cluster-randomized controlled trial (N = 1945) conducted in rural Karnataka, India, from January 2017 to February 2019. The evaluated behaviour change interventions were developed using the risks, attitudes, norms, abilities, and self-regulation (RANAS) approach. Results showed that latrine use changed by more than 15% in both treatment and control arms. The intervention triggered an additional, statistically significant increase in latrine use of approximately 5% to reach 97% use at endline. The results suggest that external factors had a strong influence on latrine use, with intensive efforts by SBM likely to be among these. The added value of the campaign was to increase latrine use to almost complete uptake and to successfully tackle the most change-resistant individuals. This intervention or selected components could complement future latrine use promotion in India.

Conversion of cemented revision total knee prostheses to arthrodesis using custom-made arthrodesis modules that preserve the cemented stem anchorage in patients with long-established extensor mechanism insufficiency: A case series.

INTRODUCTION: Long-established extensor mechanism insufficiency that defies reconstruction is a rare, but devastating, complication after revision total knee arthroplasty (RTKA) that may require arthrodesis. For cemented stem guided knee prostheses with firmly attached stems, prosthesis explantation can lead to significant bone stock loss that may, at worst, make knee arthrodesis significantly more difficult or impossible to achieve. Under these circumstances, conversion of the cemented knee prosthesis with custom-made arthrodesis modules that preserve the existing stem anchorage may be a low-risk alternative. This case series presents this type of conversion to arthrodesis, which was performed for patients with a non-reconstructable, long-established extensor mechanism insufficiency. METHODS: After intraoperatively ascertaining that reconstruction of the extensor mechanism insufficiency was impossible, the inlying revision prosthesis was converted into arthrodesis with custom-made arthrodesis modules, without explanting the cemented stems. RESULTS: Conversion to arthrodesis was performed in four patients. There was no histopathological or microbiological evidence of a periprosthetic joint infection. Clinical follow-up showed a low level of pain, with a stable knee joint and proper implant position. The Oxford Knee Score increased from 20.5 (95% CI 17-26) to 35.5 (95% CI 30-36) points. The visual analog scale decreased from 5.5 (95% CI 4-7) pre-operatively to 1.5 (95% CI 1-2) points at last follow-up. No implant-specific complications occurred. CONCLUSIONS: Conversion of cemented RTKA with firmly attached cemented stems, without evidence of loosening, to arthrodesis might be a surgical treatment strategy for patients with a long-established extensor mechanism insufficiency that cannot be reconstructed.

Shoulder Stiffness - How to Treat? / Schultersteife ­ wann und wie behandeln?

Shoulder stiffness is a condition of restricted glenohumeral range of motion, which can arise spontaneously or as consequence of a known cause, including surgical procedures on the shoulder. Several approaches to shoulder stiffness have been proposed and high-level evidence is available to analyze and discuss their results. The aim of this review was to summarize the current concepts on conservative and operative treatment of shoulder stiffness and discuss the results of the available studies with a high level of evidence, which should be considered to guide clinical practice. Treatment of shoulder stiffness should be tailored to the patient's clinical situation and the stage of its shoulder pathology and should aim at pain reduction, restoration of range of motion, functional regain and shortening of symptoms duration. When possible, known risk factors for primary shoulder stiffness and causes of secondary shoulder stiffness should be addressed to avoid relapse. Conservative therapy is the mainstay of treatment for shoulder stiffness and should include a multimodal and activity-oriented program. Intra-articular injection of a low dose of corticosteroid is safe and effective, provides immediate benefits, and is recommended in combination to an appropriate rehabilitation protocol. In conservative refractory cases, arthrolysis and capsular release can be performed with an arthroscopic approach.

Construction of a Low-cost Mobile Incubator for Field and Laboratory Use.

Incubators are essential for a range of culture-based microbial methods, such as membrane filtration followed by cultivation for assessing drinking water quality. However, commercially available incubators are often costly, difficult to transport, not flexible in terms of volume, and/or poorly adapted to local field conditions where access to electricity is unreliable. The purpose of this study was to develop an adaptable, low-cost and transportable incubator that can be constructed using readily available components. The electronic core of the incubator was first developed. These components were then tested under a range of ambient temperature conditions (3.5 °C - 39 °C) using three types of incubator shells (polystyrene foam box, hard cooler box, and cardboard box covered with a survival blanket). The electronic core showed comparable performance to a standard laboratory incubator in terms of the time required to reach the set temperature, inner temperature stability and spatial dispersion, power consumption, and microbial growth. The incubator set-ups were also effective at moderate and low ambient temperatures (between 3.5 °C and 27 °C), and at high temperatures (39 °C) when the incubator set temperature was higher. This incubator prototype is low-cost (< 300 USD) and adaptable to a variety of materials and volumes. Its demountable structure makes it easy to transport. It can be used in both established laboratories with grid power or in remote settings powered by solar energy or a car battery. It is particularly useful as an equipment option for field laboratories in areas with limited access to resources for water quality monitoring.

Treatment of Primary Shoulder Stiffness: Results of a Survey on Surgeon Practice Patterns in Italy.

Objectives Shoulder stiffness is a condition of restricted glenohumeral range of motion (ROM), which can arise spontaneously or as consequence of a known cause. Several treatment options are available and currently no consensus has been obtained on which treatment algorithm represents the best choice for the patient. The aim of this study was to investigate surgeon practice patterns in Italy regarding treatment of primary shoulder stiffness. Methods A literature review was performed to identify randomized controlled trials reporting results of shoulder stiffness treatment. The following controversial or critical points in the treatment of primary shoulder stiffness were identified: modalities of physical therapy; indication for oral corticosteroid; indication and frequency for injective corticosteroid; technique and site of injection; and indication, timing, and technique for surgery. A survey composed by 14 questions was created and administrated to the members of a national association specialized in orthopaedics and sports traumatology (SIGASCOT at the time of survey completion, recently renamed SIAGASCOT after the fusion of the societies SIGASCOT and SIA). Results A total of 204 completed questionnaires were collected. Physical therapy was recommended by 98% of the interviewed. The use of oral corticosteroids was considered by 51%, and injections of corticosteroids by 72%. The posterior injection approach was the one preferred and a number of three was considered the upper limit for repeated injections. Injective therapy with local anesthetics and hyaluronic acid was considered by more than 20% of the interviewed. Thirty percent of the interviewed did not treat shoulder stiffness surgically. Conclusion Several approaches to shoulder stiffness have been proposed and high-level evidence is available to analyze and discuss their results. Several controversial points emerged both from a literature review and from this national survey. Treatment of shoulder stiffness should be tailored to the patient's clinical situation and the stage of its pathology and should aim at pain reduction, ROM restoration, functional regain, and shortening of symptoms duration, with conservative therapy remaining the mainstay of treatment.

A case series of cementless revision total knee arthroplasty in patients with benzoyl peroxide allergy.

PURPOSE: The contact allergens nickel, cobalt, and chromium are often discussed as possible triggers of allergic reactions to orthopedic implants. Additionally, acrylates and polymerization additives in bone cement (e.g., benzoyl peroxide (BPO)) have been implicated as triggers of eczema, wound healing disorders, and aseptic implant loosening. We report about six patients with aseptic loosening after total knee arthroplasty (TKA), who underwent revision surgery after testing positive for BPO hypersensitivity. METHODS: After clarification of possible other causes of implant failure, epicutaneous testing had been performed and the implants were replaced in a two-stage procedure with cementless, diaphyseal anchoring, hypoallergenic (TiNb-coated) revision endoprostheses. RESULTS: Epicutaneous testing revealed a BPO allergy in all six patients and an additional nickel allergy in three of the six patients. There was no histopathological or microbiological evidence for a periprosthetic infection. The clinical follow-up showed a low level of pain with good function, a stable knee joint, and proper implant position. The Knee Society Score (KSS) with its subscales Knee Score and Functional Score improved post-operatively from 43 to 70 points and from 47.5 to 68.3 points, respectively. Two implant-specific complications occurred: femoral stress shielding two years post-operatively with no further need for action and aseptic loosening of the tibial stem with the need of revision three years post-operatively. CONCLUSIONS: The regression of complaints after replacement with cementless and nickel-free revision implants suggests allergic implant intolerance. Implantation of a cementless, hypoallergenic endoprosthesis might, therefore, be a surgical treatment strategy in patients with evidence of allergies.

Promoting latrine use in rural Karnataka using the risks, attitudes, norms abilities and self-regulation (RANAS) approach

This study assesses the impact of a behaviour change intervention using the risks, attitudes, norms, abilities and self-regulation (RANAS) approach for improving latrine use in the context of India's Swattch Bharat Mission (SBM) sanitation campaign.

Comparison of two-stage revision arthroplasty and intramedullary arthrodesis in patients with failed infected knee arthroplasty.

BACKGROUND: Failed total knee arthroplasty (TKA) with significant bone loss and compromised soft-tissues is challenging and the final results are often inferior to patient's expectation. The objective of this study was to present a comparison of outcomes in patients with failed infected TKA treated with two-stage revision TKA or knee arthrodesis and to assess clinical and functional results, implant survival and infection recurrence. The hypothesis was that an arthrodesis may result in beneficial effects on patients' outcome. METHODS: Clinical data of 81 patients with periprosthetic joint infection (PJI) of the knee joint were collected and analyzed retrospectively. Between 2008 and 2014, a total of 36 patients had been treated within a two-stage exchange procedure and reimplantation of a modular intramedullary arthodesis nail and 45 patients with revision TKA. Patients were treated according to the same structured treatment algorithm. Clinical and functional evaluation was performed using the Oxford knee score (OKS) and the visual analogue scale (VAS). RESULTS: The mean follow-up was 32.9 ± 14.0 months. The rate of definitely free of infection at last follow-up in the arthrodesis group was 32 of 36 (88.9%) and 36 of 45 (80.0%) in the revision TKA group (p = 0.272). Mean VAS for pain in the arthrodesis group was 3.1 ± 1.4 compared to 3.2 ± 1.6 in the revision TKA group (p = 0.636). The OKS in the arthrodesis group was 38.7 ± 8.9 and 36.5 ± 8.9 (p = 0.246) in patients with revision TKA. Rate of revisions in the revision-TKA group was 2.8 ± 3.7 compared to 1.2 ± 2.4 in the arthrodesis group (p = 0.021). CONCLUSION: Treatment of PJI needs a distinct therapy with possible fallback strategies in case of failure. A knee arthrodesis is a limb salvage procedure that showed no significant benefits on the considered outcome factors compared to revision TKA but is associated with significantly lower revision rate. After exhausted treatment modalities, a knee arthrodesis should be considered as an option in selected patients. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

[Basic Clinical Examination of the Shoulder]. / Klinische Basisuntersuchung der Schulter.

OBJECTIVE: Successful treatment of shoulder disease requires an accurate diagnosis. In addition to differentiated history taking, clinical examination is the most important component in the diagnosis of shoulder diseases. METHOD: The present video explains the common provocation tests and functional tests that are used in the basic clinical examination of the shoulder. In addition to general inspection and palpation, the focus is on different diagnostic tests and clinical signs that improve diagnostic accuracy. CONCLUSION: The present basic clinical examination methods allow a structured approach to clinical issues and can be a good basis, if supplemented by further specific and individual tests.

[Basic Clinical Examination of the Knee Joint]. / Klinische Basisuntersuchung des Kniegelenkes.

OBJECTIVE: Successful treatment of knee joint disease requires an accurate diagnosis. In addition to a differentiated history, clinical examination is the most important component in the diagnosis of knee joint diseases. METHOD: The present video explains the common provocation and functional tests that are used in the basic clinical examination of the knee joint. In addition to general inspection and palpation, the focus here is on the individual region's patella, menisci, cruciate ligaments and collateral ligaments. CONCLUSION: The present methods of basic clinical examination allow a structured approach to clinical issues and can be a good basis for the diagnosis of knee joint diseases, if supplemented by further specific and individual tests.

Escherichia coli Contamination across Multiple Environmental Compartments (Soil, Hands, Drinking Water, and Handwashing Water) in Urban Harare: Correlations and Risk Factors.

Escherichia coli pathotypes (i.e., enteropathogenic and enterotoxigenic) have been identified among the pathogens most responsible for moderate-to-severe diarrhea in low- and middle-income countries (LMICs). Pathogenic E. coli are transmitted from infected human or animal feces to new susceptible hosts via environmental reservoirs such as hands, water, and soil. Commensal E. coli, which includes nonpathogenic E. coli strains, are widely used as fecal bacteria indicator, with their presence associated with increased likelihood of enteric pathogens and/or diarrheal disease. In this study, we investigated E. coli contamination in environmental reservoirs within households (N = 142) in high-population density communities of Harare, Zimbabwe. We further assessed the interconnectedness of the environmental compartments by investigating associations between, and household-level risk factors for, E. coli contamination. From the data we collected, the source and risk factors for E. coli contamination are not readily apparent. One notable exception is the presence of running tap water on the household plot, which is associated with significantly less E. coli contamination of drinking water, handwashing water, and hands after handwashing. In addition, E. coli levels on hands after washing are significantly associated with handwashing water contamination, hand contamination before washing, and diarrhea incidence. Finally, we observed that animal ownership increases E. coli contamination in soil, and E. coli in soil are correlated with contamination on hands before washing. This study highlights the complexity of E. coli contamination in household environments within LMICs. More, larger, studies are needed to better identify sources and exposure pathways of E. coli-and enteric pathogens generally-to identify effective interventions.

Enhancing handwashing frequency and technique of primary caregivers in Harare, Zimbabwe: A cluster-randomized controlled trial using behavioral and microbial outcomes.

RATIONALE: Consistent hand hygiene prevents diarrheal and respiratory diseases, but it is often not practiced. The disease burden is highest in low-income settings, which need effective interventions to promote domestic handwashing. To date, most handwashing campaigns have focused on promoting frequent handwashing at key times, whereas specifically promoting handwashing techniques proven to be effective in removing microbes has been confined to healthcare settings. METHODS: We used a cluster-randomized, factorial, controlled trial to test the effects of two handwashing interventions on the behavior of primary caregivers in Harare, Zimbabwe. One intervention targeted caregivers directly, and the other targeted them through their children. Outcome measures were surveyed at baseline and six weeks' follow-up and included observed handwashing frequency and technique and fecal hand contamination before and after handwashing. RESULTS: Combining the direct and indirect interventions resulted in observed handwashing with soap at 28% of critical handwashing times, while the corresponding figure for the non-intervention control was 5%. Observed handwashing technique, measured as the number of correctly performed handwashing steps, increased to an average of 4.2, while the control averaged 3.4 steps. Demonstrated handwashing technique increased to a mean of 6.8 steps; the control averaged 5.2 steps. No statistically significant group differences in fecal hand contamination before or after handwashing were detected. CONCLUSIONS: The results provide strong evidence that the campaign successfully improved handwashing frequency and technique. It shows that the population-tailored design, based on social-cognitive theory, provides effective means for developing powerful interventions for handwashing behavior change. We did not find evidence that children acted as strong agents of handwashing behavior change. The fact that the microbial effectiveness of handwashing did not improve despite strong improvements in handwashing technique calls for critical evaluation of existing handwashing recommendations. The aim of future handwashing campaigns should be to promote both frequent and effective handwashing.

Activity Pattern Analysis Indicates Increased but Balanced Systemic Coagulation Activity in Response to Surgical Trauma.

In the nonbleeding patient, constant low-level activation of coagulation enables a quick procoagulant response upon an injury. Conversely, local activation of coagulation might influence the systemic activity level of coagulation. To characterize this interaction in more detail, activity pattern analysis was performed in patients undergoing elective surgeries. Blood samples were taken before, during, and 24 hours after surgery from 35 patients undergoing elective minor ( n = 18) and major ( n = 17) orthopaedic surgeries. Plasma levels of thrombin and activated protein C (APC) were measured using oligonucleotide-based enzyme capture assays, while those of prothrombin fragment 1.2, thrombin-antithrombin-complexes, and D-dimer were measured using commercially available enzyme-linked immunosorbent assays. In vitro thrombin generation kinetics were recorded using calibrated automated thrombography. Results showed that median plasma levels of up to 20 pM thrombin and of up to 12 pM APC were reached during surgery. D-dimer levels started to increase at the end of surgery and remained increased 24 hours after surgery, while all other parameters returned to baseline. Peak levels showed no significant differences between minor and major surgeries and were not influenced by the activity state at baseline. In vitro thrombin generation kinetics remained unchanged during surgery. In summary, simultaneous monitoring of the procoagulant and anticoagulant pathways of coagulation demonstrates that surgical trauma is associated with increased systemic activities of both pathways. Activity pattern analysis might be helpful to identify patients at an increased risk for thrombosis due to an imbalance between surgery-related thrombin formation and the subsequent anticoagulant response.

Identifying behavioural determinants for interventions to increase handwashing practices among primary school children in rural Burundi and urban Zimbabwe.

BACKGROUND: This article presents the development of a school handwashing programme in two different sub-Saharan countries that applies the RANAS (risk, attitudes, norms, ability, and self-regulation) systematic approach to behaviour change. METHODS: Interviews were conducted with 669 children enrolled in 20 primary schools in Burundi and 524 children in 20 primary schools in Zimbabwe. Regression analyses were used to assess the influence of the RANAS behavioural determinants on reported handwashing frequencies. RESULTS: The results revealed that, in both countries, a programme targeting social norms and self-efficacy would be most effective. In Burundi, raising the children's perceived severity of the consequences of contracting diarrhoea, and in Zimbabwe, increasing the children's health knowledge should be part of the programme. CONCLUSIONS: The school handwashing programme should create awareness of the benefits of handwashing through educational activities, raise the children's ability and confidence in washing hands at school through infrastructural improvements, and highlight the normality of washing hands at school through events and poster creation.