Financial burden of orthopaedic gunshot-related injury management at a major trauma centre.

BACKGROUND: Violence and injuries are a significant global public health concern, and have a substantial emotional, physical and economic impact on society. In South Africa (SA), the Western Cape Injury Mortality Profile shows that homicides increased from 38 deaths per 100 000 in 2010 to 52 deaths per 100 000 in 2016. This increase is directly related to an increase in firearm-related homicides, which doubled from 2010 to 2016. Previous research estimated the average cost per gunshot wound (GSW)-related orthopaedic patient at USD2 940. GSW-related patient numbers as well as treatment costs have escalated exponentially over the past few years. OBJECTIVES: To calculate the financial costs involved in managing gunshot-related orthopaedic injuries both surgically and non-surgically at a tertiary centre in SA. METHODS: After ethics approval, a retrospective review of all GSW patients seen in the emergency unit at Tygerberg Hospital in 2017 was undertaken. Patient records yielded data on the following parameters: injury site and characteristics, imaging modalities, orthopaedic management, hospital admission and duration of hospitalisation, theatre episodes, orthopaedic implants and blood products administered. Cost analysis was performed using this information. RESULTS: A total of 389 patients (360 male and 29 female), average age (range, standard deviation) 28 (3 - 69, 9.50) years, were treated during the study period. Patient records identified a total of 449 orthopaedic injuries. A total of 187 patients were admitted, with 175 requiring surgical fixation. The conservatively calculated cost of managing this patient group was ZAR10 227 503. The average management cost per patient was ZAR26 292, with an average of ZAR46 670 per case requiring surgical management and ZAR8 810 for non-surgical cases (the average USD-ZAR exchange rate in 2017 was USD1-ZAR13.30). CONCLUSIONS: The total cost of managing 389 patients with gunshot-related orthopaedic injuries at a tertiary hospital was ZAR10 227 503. Improved understanding of these costs will help the healthcare system better prioritise orthopaedic trauma funding and training and highlights the urgent need for cost-saving measures, specifically primary prevention initiatives.

The epidemiology and orthopaedic burden of civilian gunshot injuries over a four-year period at a level one trauma unit in Cape Town, South Africa.

PURPOSE: The aim of this study was to quantify the overall burden of orthopaedic gunshot-related injuries at our institution over a four year period. Secondary aims included identifying complications from gunshot-related injuries and the additional burden it places on healthcare services. METHODS: A retrospective review was conducted on all patients with gunshot injuries presenting to our hospital's trauma unit between January 2014 and December 2017. Patient data was recorded, and demographic data, number and type of implants, blood products used, duration of hospital admission, duration of ICU admission, radiological studies performed, and prevalence of complications were analysed. RESULTS: A total of 1449 patients with a mean age of 28.2 ± 9.7 years (range 2.0-71.0) were included in this study. The majority of these gunshot-related orthopaedic injuries were sustained to the lower extremities and were treated non-operatively. The median duration of hospital stay was 7.0 (IQR 4.0-12.0). The most common complications identified were nerve injury (8.3%), vascular injury (6.5%), fracture-related infection (3.2%), non-union (3.1%), and compartment syndrome (1.6%). The total cost of care was ZAR 53,568,537 (USD 4,320,043) with an average cost per patient of ZAR 37,031 (USD 2986). CONCLUSION: This study highlighted the burden of gunshot injuries presenting to our hospital and the strain it places on its healthcare resources. The prevalence of complications was comparable to international studies on the subject. With improved understanding of this burden, more healthcare resources can be allocated to this problem and better prevention strategies can be planned.

Roles of nitric oxide in the homeostatic control of the excitation-inhibition balance in rat visual cortical networks.

The level of excitability of cortical neurons depends on the balance between their excitatory and inhibitory inputs (excitation/inhibition [E/I] balance). In the cortex, the E/I balance received by a neuron is dynamically maintained through a coordinated regulation of the strength of these inputs, described in term of homeostatic plasticity. Using a method allowing the determination of the E/I balance in rat cortical layer 5 pyramidal neurons (L5-PNs, the main output stage of the cortex), while keeping the interactions between excitatory and inhibitory networks functional, we examined the effects of high or low frequency of stimulation (HFS or LFS) protocols in layer 4 (in order to mimic thalamo-cortical entries) on the E-I level of the neuronal network. We previously showed that the E/I balance of L5-PNs remains stable due to a dual potentiation or dual depression of E and I after HFS or LFS protocols. Here, using a specific neuronal nitric oxide synthase (nNOS) inhibitor, we show that the related potentiation or depression of E and I (underlying homeostatic plasticity processes) required nNOS activation. We also show that application of an unspecific blocker of nitric oxide synthase (NOS) or a nitric oxide (NO) scavenger induces an increase of the E/I balance suggesting a role for a tonic NO synthesis in the regulation of the network activity. It is concluded that, in the cortex, a phasic NO effect (due to activation of nNOS) is required for the induction of homeostatic plasticity processes whereas a tonic NO signal is involved in the regulation of a set-point value for the E/I balance.

Impaired GABAergic transmission disrupts normal homeostatic plasticity in rat cortical networks.

In the cortex, homeostatic plasticity appears to be a key process for maintaining neuronal network activity in a functional range. This phenomenon depends on close interactions between excitatory and inhibitory circuits. We previously showed that application of a high frequency of stimulation (HFS) protocol in layer 2/3 induces parallel potentiation of excitatory and inhibitory inputs on layer 5 pyramidal neurons, leading to an unchanged excitation/inhibition (E/I) balance. These coordinated long-term potentiations of excitation and inhibition correspond to homeostatic plasticity of the neuronal networks. We showed here, on the rat visual cortex, that blockade (with gabazine) or overactivation (with 4,5,6,7-tetrahydroisoxazolo[5,4-c]pyridin-3-ol) of GABA(A) receptors enhanced the E/I balance and prevented the potentiation of excitatory and inhibitory inputs after an HFS protocol. These impairements of the GABAergic transmission led to a long-term depression-like effect after an HFS protocol. We also observed that the blockade of inhibition reduced excitation (by 60%), and conversely, the blockade of excitation decreased inhibition (by 90%). These results support the idea that inhibitory interneurons are critical for recurrent interactions underlying homeostatic plasticity in cortical networks.

[Collections of human biological resources for research purposes: from regulations to the need of a guide of good collection practices]. / Les collections de ressources biologiques humaines pour la recherche : de la réglementation à la mise en place d'un guide de bonnes pratiques du collectionneur.

PURPOSE: In France, collections of human biological resources are regulated by the "Bioethics Law", currently in revision. Hence, we analyse the regulatory and ethical issues of these practices in the context of scientific research. The ultimate aim of such collections is to improve biological and medical knowledge. CURRENT KNOWLEDGE AND KEY POINTS: We think that the French regulatory system is quite complicated and non-explicit for "collection holders". The multiplicity of legal texts concerning this activity has made their application difficult, especially in the absence of application decrees. The project amending the actual law has clarified the legal status of collections but it did not shed light on the status of human body detached parts. Furthermore, the text is still very far from the international bioethical recommendations, and does not reflect the actual collection's implementation. FUTURE PROSPECTS AND PROJECTS: The establishment of a guideline of Good Collection Practices, based on clear principles, should help to simplify the situation, especially when it is imbedded in the regulation and linked to control procedures. It would allow a balance between collective interests and the protection of individuals, taking into account of the international highly competitive scientific and economical constraints. The major issue is to preserve and to perpetuate the existing and future collections because of their precious value as an important tool for biomedical knowledge. The efficiency of a regulation depends on its legibility and accessibility, two requirements that seem to determine the acceptance of the regulatory tool and its application allowing subsequently to reach fairness in proceedings.

Prolonged mivacurium neuromuscular block in children.

The authors report two cases of prolonged neuromuscular block after administration of mivacurium in children with previously undiagnosed plasma cholinesterase deficiency related to homozygous atypical genotype. Their anaesthetic management is described as well as determination of the phenotype of both children and their family.

[Intracytoplasmic injection of spermatozoa (ICSI). Ethical requirements and assessment]. / Injection intracytoplasmique de spermatozoïde (ICSI). Enjeux éthiques et évaluation.

There is no doubt that the clinical application of intracytoplasmic sperm injection (ICSI) has been a major breakthrough in the treatment of extremely severe male-factor infertility. We analyzed the impact of ICSI on medically assisted reproduction practices. The potential of risks ICSI, whether related to abnormalities associated with male infertility, penetration within the ovocyte or the risk of introducing foreign material, should not be neglected. With ICSI, a situation of human experimentation has been created without adequate prior animal experimentation and research has been conducted without the approval of ethics committees as required by the Huriet Law in France. When first introduced, ICSI was not accompanied by an evaluation protocol to follow the biological risks and societal impact. We thus believe that meeting the requirements of the following ethical criteria deserves discussion. ICSI should still be considered as an experimental clinical procedure. Risk should be evaluated with animal models since all forms of spermatozoa can now be injected into mouse oocytes. Complete independence is needed for biological and genetic assessment, pediatric follow-up on children born and societal and health care impact. Scientific personnel as well as patients and the society in general should be continuously informed of the status of the evaluation work. As for any experimental therapy, the process of obtaining informed consent takes on special significance. Careful explanation of the procedure is needed so the patients can be in a position to determine what level of risk is acceptable.