Epidemiology and outcomes of geriatric trauma patients consulting at the center hospitalier universitaire de Kigali emergency department

Background Life expectancy in low- and middle-income countries (LMIC) continues to rise, resulting in a growing geriatric population. In Rwanda, a sub-Saharan LMIC, traumatic injuries are a common cause of mortality and morbidity. However, little is known about the frequency and type of traumatic injuries among geriatric populations in Rwanda. Objective We explored the epidemiology and outcomes of trauma for geriatric patients presenting to the emergency department (ED) of the center Hospitalier Universitaire de Kigali (CHUK) in Rwanda. Methods This prospective cross-sectional study was conducted from July 2019 to January 2020 at the ED of CHUK. Trauma patients aged 65 and above and alive at the time of evaluation were eligible for inclusion. Demographic characteristics were collected along with triage category, mechanism of injury, transfer status, transport method to CHUK, time spent at the ED, complications, and mortality predictors. Results For the 100 patients enrolled, the most common injury mechanism was falls (63%), followed by road traffic accidents (28%). The majority of patients spent less than 48 h in the ED (63%). The mortality rate was 14%, with most deaths resulting from injury-related complications. Triage category, Kampala Trauma Score, and Glasgow Coma Scale were significant predictors of mortality, with p-values of 0.002, <0.001, and <0.001, respectively. Conclusions The epidemiology of geriatric trauma found in this study can inform public health and clinical guidelines. Interventions targeting falls and road traffic accidents would target the most common geriatric trauma mechanisms, and clinical protocols that take into account predictors of mortality could improve outcomes and increase life expectancy for this population.

Rotator cuff repair: what questions are patients asking online and where are they getting their answers?

Background@#This study analyzed questions entered online by rotator cuff patients and determined types and quality of websites providing information at the top of queries. @*Methods@#Three strings related to rotator cuff repair were explored in Google Search. The result pages were manually collected under the “People also ask” function for frequent questions and associated webpages. Questions were categorized using Rothwell’s classification with further topical subcategorization. Webpages were evaluated by Journal of American Medical Association (JAMA) benchmark criteria for source quality. @*Results@#One hundred twenty “People also ask” questions were collected with their associated webpages. Based on the Rothwell classification of questions, queries were thematically organized into fact (41.7%), value (31.7%), and policy (26.7%) categories. The most common webpage categories were academic (28.3%) and medical practice (27.5%). The most common question subcategories were timeline of recovery (21.7%), indications/management (21.7%), and pain (18.3%). The average JAMA score for all 120 webpages was 1.50. Journal articles had the highest average JAMA score (3.77), while commercial websites had the lowest JAMA score (0.91). The most common suggested question for rotator cuff repair/surgery was, “Is rotator cuff surgery worth having?,” while the most common suggested question for rotator cuff repair pain was, “What happens if a rotator cuff is not repaired?” @*Conclusions@#The most common questions asked on Google pertaining to rotator cuff repair evaluate management options and relate to the timeline of recovery and pain management. Most information is provided by medical practice, academic, and medical information websites, which have highly variable reliability. By understanding the questions that rotator cuff repair patients are asking online, surgeons can tailor preoperative education to common patient concerns and improve postoperative outcomes.Level of evidence: IV.

Internet search analytics for shoulder arthroplasty: what questions are patients asking?

Background@#Common questions about shoulder arthroplasty (SA) searched online by patients and the quality of this content are unknown. The purpose of this study is to uncover questions SA patients search online and determine types and quality of webpages encountered. @*Methods@#The “People also ask” section of Google Search was queried to return 900 questions and associated webpages for general, anatomic, and reverse SA. Questions and webpages were categorized using the Rothwell classification of questions and assessed for quality using the Journal of the American Medical Association (JAMA) benchmark criteria. @*Results@#According to Rothwell classification, the composition of questions was fact (54.0%), value (24.7%), and policy (21.3%). The most common webpage categories were medical practice (24.6%), academic (23.2%), and medical information sites (14.4%). Journal articles represented 8.9% of results. The average JAMA score for all webpages was 1.69. Journals had the highest average JAMA score (3.91), while medical practice sites had the lowest (0.89). The most common question was, “How long does it take to recover from shoulder replacement?” @*Conclusions@#The most common questions SA patients ask online involve specific postoperative activities and the timeline of recovery. Most information is from low-quality, non-peer-reviewed websites, highlighting the need for improvement in online resources. By understanding the questions patients are asking online, surgeons can tailor preoperative education to common patient concerns and improve postoperative outcomes.

Variability in physical therapy protocols following total shoulder arthroplasty

Background@#Physical therapy (PT) plays an important role in the recovery of function following anatomic total shoulder arthroplasty (aTSA). While several PT protocols have been published for these patients, there is no standardized protocol for aTSA rehabilitation. This lack of standardization may lead to confusion between patients and physicians, possibly resulting in suboptimal outcomes. This study examines how PT protocols provided by academic orthopedic surgery programs vary regarding therapeutic goals and activities following aTSA. @*Methods@#PT protocols for aTSA available online from the Accreditation Council for Graduate Medical Education accredited orthopedic surgery programs were included for review. Each protocol was analyzed to evaluate it for differences in recommendation of length of immobilization, range of motion (ROM) goals, start time for and progression of therapeutic exercises, and timing for return to functional activity. @*Results@#Of 175 accredited programs, 25 (14.2%) had protocols publicly available, programs (92%) recommended sling immobilization outside of therapy for an average of 4.4±2.0 weeks. Most protocols gave recommendations on starting active forward flexion (24 protocols, range 1–7 weeks), external rotation (22 protocols, range 1–7 weeks), and internal rotation (18 protocols, range 4–7 weeks). Full passive ROM was recommended at 10.8±5.7 weeks, and active ROM was 13.3±3.9 weeks, on average. ROM goals were inconsistent among protocols, with significant variations in recommended ROM and resistance exercise start times. Only 13 protocols (52%) gave recommendations on resuming recreational activities (mean, 17.4±4.4 weeks). @*Conclusions@#Publicly available PT protocols for aTSA rehabilitation are highly variable.Level of evidence: IV.

Clinical trial of halofantrine with modified doses for treatment of malaria in the hospital for tropical diseases.

The spread of falciparum malaria resistant to chloroquine all over Southeast Asian continent has led to increasing use of alternative antimalarial drugs. Halofantrine has been shown to be effective against multidrug resistant Plasmodium falciparum. One hundred and twenty falciparum malaria cases were randomly assigned to one of three different halofantrine regimes. Group I (HA1) received 500 mg three times daily for 3 days (total dose: 4,500 mg), group II (HA2) received 500 mg three times daily for the first and the third day (total dose: 3,000 mg) and group III (HA3) received 500 mg three times for one day followed by 500 mg once daily for 7 days (total dose: 4,500 mg). No significant difference in the cure rate was observed among the three regimes (cure rate: 89%, 73%, 97% respectively). However, the cure rate was significantly higher in the HA3 group when compared to the HA2 group. There were no overt cardiac problems seen in this study. Thus, halofantrine has high efficacy in the recommended treatment dose of 500 mg three times after meals on the first day followed by 500 mg once a day after a meal for 7 days (total dose: 4,500 mg).

Effects of hydroxypyridinone iron chelators in combination with antimalarial drugs on the in vitro growth of Plasmodium falciparum.

Using standard in vitro drug susceptibility methods, we assessed the antimalarial activity of 3 orally administered iron chelators (hydroxypyridinones) alone and in combination with conventional antimalarials drugs (quinine, mefloquine, artesunate, tetracycline, atovaquone) against a chloroquine-resistant Plasmodium falciparum isolate. When tested alone, all iron chelators and antimalarial compounds inhibited the growth of the parasites. IC50 values for iron chelators were 60-70 microM, whereas the IC50 values for antimalarial drugs were in nM ranges, with artesunate being the most potent. The derived isobolograms for the interaction of hydroxypyridinones and antimalarial drugs showed addition or mild antagonism, similar to desferroxamine (Sum of Fractional Inhibitory Concentration, sigma FIC < 0.5 or > 4.0). Despite the absence of synergy with conventional drugs, intrinsic antimalarial activity of hydroxypyridinones supports the continued assessment of these iron chelators as treatment adjuncts.

Mutations in Plasmodium falciparum dihydrofolate reductase and dihydropteroate synthase of isolates from the Amazon Region of Brazil

Since the late 1970s pyrimethamine-sulfadoxine (PS; FansidarTM Hoffman-LaRoche, Basel) has been used as first line therapy for uncomplicated malaria in the Amazon basin. Unfortunately, resistance has developed over the last ten years in many regions of the Amazon and PS is no longer recommended for use in Brazil. In vitro resistance to pyrimethamine and cycloguanil (the active metabolite of proguanil) is caused by specific point mutations in Plasmodium falciparum dihydrofolate reductase (DHFR), and in vitro resistance to sulfadoxine has been associated with mutations in dihydropteroate synthase (DHPS). In association with a proguanil-sulfamethoxazole clinical trial in Brazil, we performed a nested mutation-specific polymerase chain reaction to measure the prevalence of DHFR mutations at codons 50, 51, 59, 108 and 164 and DHPS mutations at codons 436, 437, 540, 581 and 613 at three sites in the Brazilian Amazon. Samples from two isolated towns showed a high degree of homogeneity, with the DHFR Arg-50/Ile-51/Asn-108 and DHPS Gly-437/Glu-540/Gly-581 mutant genotype accounting for all infections in Peixoto de Azevedo (n = 15) and 60 percent of infections in Apiacás (n = 10), State of Mato Grosso. The remaining infections in Apiacás differed from this predominant genotype only by the addition of the Bolivia repeat at codon 30 and the Leu-164 mutation in DHFR. By contrast, 17 samples from Porto Velho, capital city of the State of Rondônia, with much in- and out-migration, showed a wide variety of DHFR and DHPS genotypes.

Pharmacokinetics of proguanil in malaria patients treated with proguanil plus atovaquone.

Clinical studies have shown atovaquone (ATQ), a new blood schizontocidal drug, in combination with proguanil (PROG) to be very effective in the treatment of acute multidrug-resistant falciparum malaria. The multiple dose pharmacokinetics of PROG were determined in Thai patients with acute falciparum malaria given PROG alone (200 mg PROG twice a day for 3 days, n = 4) and concurrently PROG and ATQ (200 mg PROG and 500 mg ATQ twice a day for 3 days, n = 12). There were no statistical differences (p > 0.05) in the area under the plasma drug concentration-time curve (AUC), apparent oral clearance (CL/F) and elimination half-life (t1/2) of PROG between patients given PROG alone and PROG/ ATQ. The median (range) kinetic values of PROG in patients given PROG alone and PROG/ATQ were respectively: CL/F = 1.25 l/h/kg (0.99-1.45) and 0.95 (0.73-1.32) l/h/kg, and t1/2 = 14.2 hours (9.3-16.8) and 13.6 hours (9.1-17.6). The CL/F and t1/2 of PROG in the Thai patients treated with the 2 treatment regimens were also comparable to values reported in healthy Thai volunteers given a standard prophylactic dose (200 mg PROG). The results of this preliminary study suggest that ATQ is unlikely to affect the pharmacokinetics of PROG to a clinically important extent at an ATQ dosage of 500 mg twice a day for 3 days in malaria infected patients.

Treatment of acute uncomplicated falciparum malaria with a short course of artesunate followed by mefloquine.

The clinical results of this study indicate that a half-dose regimen of artesunate followed by mefloquine produces an acceptable cure rate when compared to other commonly available drugs for treating acute uncomplicated falciparum malaria in Thailand. The 90% cure rate was comparable to the results with either a full dose of artesunate (600 mg over 5 days) or mefloquine (25 mg/kg in divided doses six hours apart) as well as the combination of quinine-tetracycline administered for seven days. This abbreviated regimen, however was less effective than the full dose regimen of both drugs previously reported.