Timing of antibiotic administration, wound debridement, and the stages of reconstructive surgery for open long bone fractures of the upper and lower limbs.

BACKGROUND: Open fractures of the major long bones are complex limb-threatening injuries that are predisposed to deep infection. Treatment includes antibiotics and surgery to debride the wound, stabilise the fracture and reconstruct any soft tissue defect to enable infection-free bone repair. There is a need to assess the effect of timing and duration of antibiotic administration and timing and staging of surgical interventions to optimise outcomes. OBJECTIVES: To assess the effects (risks and benefits) of the timing of antibiotic administration, wound debridement and the stages of surgical interventions in managing people with open long bone fractures of the upper and lower limbs. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and clinical trial registers in February 2021. We also searched conference proceedings and reference lists of included studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) or quasi-RCTs that recruited adults with open fractures of the major long bones, comparing: 1) timings of prophylactic antibiotic treatment, 2) duration of prophylactic antibiotic treatment, 3) timing of wound debridement following injury or 4) timing of the stages of reconstructive surgery. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We aimed to collect data for the following outcomes: limb function, health-related quality of life (HRQoL), deep surgical site infection, delayed or non-union, adverse events (in the short- and long-term course of recovery), and resource-related outcomes. MAIN RESULTS: We included three RCTs of 613 randomised participants with 617 open fractures. Studies were conducted in medical and trauma centres in the USA and Kenya. Where reported, there was a higher proportion of men and a mean age of participants between 30 and 34 years old. Fractures were in the upper and lower limbs in one study, and were tibia fractures in two studies; where reported, these were the result of high-energy trauma such as road traffic accidents. No studies compared the timing of antibiotic treatment or wound debridement. Duration of prophylactic antibiotic treatment (1 study, 77 participants available for analysis) One study compared antibiotic treatment for 24 hours with antibiotic treatment for five days. We are very uncertain about the effects of different durations of antibiotic treatment on superficial infections (risk ratio (RR) 1.19, 95% CI 0.49 to 2.87, favours 5 day treatment; 1 study, 77 participants); this was very low-certainty evidence derived from one small study with unclear and high risks of bias, and with an imprecise effect estimate. This study reported no other review outcomes. Reconstructive surgery: timing of the stages of surgery (2 studies, 458 participants available for analysis) Two studies compared the timing of wound closure, which was completed immediately or delayed. In one study, the mean time of delay was 5.9 days; in the other study, the time of delay was not reported. We are very uncertain about the effects of different timings of wound closure on deep infections (RR 0.82, 95% CI 0.37 to 1.80, favours immediate closure; 2 studies, 458 participants), delayed union or non-union (RR 1.13, 95% CI 0.83 to 1.55, favours delayed closure; 1 study, 387 participants), or superficial infections (RR 6.45, 95% CI 0.35 to 120.43, favours delayed closure; 1 study, 71 participants); this was very low-certainty evidence. We downgraded the certainty of the evidence for very serious risks of bias because both studies had unclear and high risks of bias. We also downgraded for serious imprecision because effect estimates were imprecise, including the possibility of benefits as well as harms, and very serious imprecision when the data were derived from single small study. These studies reported no other review outcomes. AUTHORS' CONCLUSIONS: We could not determine the risks and benefits of different treatment protocols for open long bone fractures because the evidence was very uncertain for the two comparisons and we did not find any studies addressing the other possible comparisons. Well-designed randomised trials with adequate power are needed to guide surgical and antibiotic treatment of open fractures, particularly with regard to timing and duration of antibiotic administration and timing and staging of surgery.

More than a third of SACA countries (South and Central America) do not have coverage of insulin, supplies and lab exams

Background: The IDF Diabetes Atlas 2019 points out that SACA is the region with the highest percentage of health expenditures on diabetes, 19.4%. The total number of individuals with diabetes in the region is 31.6 million, which means a prevalence of 9.4%. Countries with the largest percentage of expenditures are Cuba (24.3%), Brazil (24.2%), and Costa Rica (21.3%), while the lowest estimates are for Argentina (5.0%) and Uruguay (6.1%). Aim: Identify if insulin, oral medicines, supplies (syringes, test strips, needles, etc.) and lab exams are fully provided (free of charge) in those countries and if there is an association between percentage of expenditures on diabetes and care provision. Method: A digital online survey with 12 multiple choice questions was shared by e-mail and WhatsApp with all IDF members organizations in the SACA region. It was open for answers between April 4th and May 5th, during the COVID-19 pandemic. The question of interest for this was specifically about access to medicines and lab exams. Mean diabetes-related expenditure (USD) per person with diabetes (20–79 years) was based on IDF Diabetes Atlas 2019 data. Wilcoxon signed-rank test was used to compare expenditures of countries providing free supplies with those without free medical supplies. Results: The questionnaire was answered by 16 of the 18 IDF SACA region countries. Colombia and El Salvador were the only countries with no response. Most of the countries reported free access to oral medicines (69%), insulins (63%), supplies (syringes, needles, test strips, etc. - 56%) and lab exams (63%). Honduras was the only country where free access started because of the COVID-19 pandemic. Associations between expenditures and provision of free oral medicines, insulins, medical supplies or exams were not statistically significant, i.e. free provision of any of the four items was not associated with higher expenditures. Discussion: Our study revealed that expenditure does not determine whether medicines, supplies and exams are provided for free or not. We hypothesize that countries spending less in providing these essential items for free are still spending similar amounts due to the high costs of treating diabetes chronic complications caused by lack of access to insulin, oral medicines, supplies and lab exams. At the same time that most of the SACA countries already count on full coverage of essential diabetes medicines and supplies, such as insulin, metformin, test strips, and exams, there are still 6 countries (Bolivia, Cuba, Dominican Republic, Ecuador, Peru and Puerto Rico) lacking coverage of 3 out of four or of all essential items. It is especially worrisome that 100 years after the discovery of insulin more than a third of the countries in SACA regions still do not count on full provision of this essential life-saving medicine.

Making Room for Zoom in Focus Group Methods: Opportunities and Challenges for Novice Researchers (During and Beyond COVID-19)

Als die COVID-19-Pandemie über die Welt hereinbrach, waren viele Menschen gezwungen, sich auf online-basierte Routinen einzustellen, darunter auch qualitative Forscher*innen, die nach alternativen Möglichkeiten zur Erhebung aussagekräftiger Daten suchten. Während Fokusgruppen traditionell Face to Face durchgeführt werden, bieten Fortschritte bei Online-Videokonferenzanwendungen neue Methoden zur Datenerhebung, die jedoch bisher nur selten untersucht wurden. In diesem Artikel berichten wir über die Erfahrungen von 12 Doktorand*innen mit der Durchführung von Fokusgruppen unter Verwendung von Zoom im Rahmen eines Kurses zu qualitativen Interviewmethoden. Wir reflektieren Chancen und Herausforderungen, die wir als Moderator*innen und Teilnehmer*innen bei der Nutzung von Zoom erlebten z.B. bei der Vorbereitung oder in Bezug auf Rapport, die Einbindung anderer digitaler Tools und von Internetverbindungen. Zusammenfassend lässt sich sagen, dass die Durchführung von Online-Fokusgruppen unter Verwendung von Zoom insgesamt eine positive Erfahrung war und mit Face-to-Face-Fokusgruppen vergleichbar ist. Möglichkeiten der Teilnehmer*innenrekrutierung, die Sicherheitsmerkmale von Zoom und die Nutzung von Zoom und allgemeiner neuen Technologien sollten auch jenseits der Pandemie weiter erforscht werden.Alternate :As the COVID-19 pandemic swept through the world, it forced many people to adapt to an online-based routine, including qualitative researchers looking for alternative ways to collect meaningful data. While focus groups are traditionally conducted in-person, advances with online videoconferencing applications present a new method to collect data, however, few studies have explored this. In this article we present 12 doctoral students' experiences with conducting focus groups using the videoconferencing application Zoom during a qualitative methods course on interviewing methods. Through this self-study qualitative analysis, participants reflected on the opportunities and challenges experienced as both moderators and participants using Zoom including: preparation, rapport, incorporating other digital tools, and internet connectivity. In conclusion, doing focus groups online using Zoom was a positive experience overall and comparable to in-person focus groups for collecting qualitative data, despite the introduction of technology. More research on participant recruitment, new technology, Zoom's security features, and Zoom's use outside of a pandemic should be further explored.

Feedback on COVIDOM: A telemedicine solution for home monitoring of patients with mild COVID-19

COVIDOM is a telemonitoring platform that has been designed for patients suspected or affected by COVID-19 and who do not require hospitalization. This tool has been co-constructed with all healthcare stakeholders (regional agencies, hospitals, and family physicians). It brings together a web application and a remote monitoring center for home monitoring of patients suffering from Covid-19. Monitoring is done via brief and standardized daily questionnaires. Currently, more than 60,000 patients have completed their follow-up in COVIDOM. COVIDOM is an innovative solution for home monitoring of patients with mild forms of COVID-19.

REducing unwarranted variation in the Delivery of high qUality hip fraCture services in England and Wales (REDUCE): protocol for a mixed-methods study.

INTRODUCTION: Substantial variation in the delivery of hip fracture care, and patient outcomes persists between hospitals, despite established UK national standards and guidelines. Patients' outcomes are partly explained by patient-level risk factors, but it is hypothesised that organisational-level factors account for the persistence of unwarranted variation in outcomes. The mixed-methods REducing unwarranted variation in the Delivery of high qUality hip fraCture services in England and Wales (REDUCE) study, aims to determine key organisational factors to target to improve patient care. METHODS AND ANALYSIS: Quantitative analysis will assess the outcomes of patients treated at 172 hospitals in England and Wales (2016-2019) using National Hip Fracture Database data combined with English Hospital Episodes Statistics; Patient Episode Database for Wales; Civil Registration (deaths) and multiple organisational-level audits to characterise each service provider. Statistical analyses will identify which organisational factors explain variation in patient outcomes, and typify care pathways with high-quality consistent patient outcomes. Documentary analysis of 20 anonymised British Orthopaedic Association hospital-initiated peer-review reports, and qualitative interviews with staff from four diverse UK hospitals providing hip fracture care, will identify barriers and facilitators to care delivery. The COVID-19 pandemic has posed a major challenge to the resilience of services and interviews will explore strategies used to adapt and innovate. This system-wide understanding will inform the development, in partnership with key national stakeholders, of an 'Implementation Toolkit' to inform and improve commissioning and delivery of hip fracture services. ETHICS AND DISSEMINATION: This study was approved: quantitative study by London, City and East Research Ethics Committee (20/LO/0101); and qualitative study by Faculty of Health Sciences University of Bristol Research Ethics Committee (Ref: 108284), National Health Service (NHS) Health Research Authority (20/HRA/71) and each NHS Trust provided Research and Development approval. Findings will be disseminated through scientific conferences, peer-reviewed journals and online workshops.

[18F]-FDG PET/CT in oncologic patients with unsuspected asymptomatic infection with SARS-CoV-2.

PURPOSE: Spain has been one of the most affected countries by the COVID-19 pandemic, being among the countries with worse numbers, including the death rate. However, most patients are asymptomatic, although they are very contagious. The objective of this study was to investigate the incidence in oncological patients infected with SARS-CoV-2 that are asymptomatic for COVID-19 and at home and that undergo PET/CT for oncologic indications, nonrelated to COVID-19, finding in the PET/CT lung alterations that are suggestive of SARS-CoV-2 infection. METHODS: During the period of maximum incidence of the global pandemic in one of the most affected regions of Spain, there were 145 patients that met inclusion and exclusion criteria and were included in the study. Imaging findings previously described such as ground-glass opacities with low [18F]-FDG uptake were considered images suspicious for SARS-CoV-2 infection. Patients with these findings were referred to RT-PCR testing and close follow-up to confirm the presence or absence of COVID-19. RESULTS: Suspicious lung imaging findings were present in 7 of 145 patients (4.8%). Five of these 7 patients were confirmed as presenting SARS-CoV-2 infection, this is, COVID-19. In the remaining two, it was not possible to confirm the presence of COVID-19 with RT-PCR, although in one of them, PET/CT allowed an early diagnosis of a lung infection related to a bacterial pneumonic infection that was promptly and adequately treated with antibiotics. CONCLUSION: These results confirm that the prevalence of SARS-CoV-2 infection is higher than suspected and that there are asymptomatic patients that are attending imaging departments to be explored for their baseline oncologic processes. In these patients, PET/CT allows an early diagnosis of COVID-19.

18F-FDG PET/CT in Hodgkin Lymphoma With Unsuspected COVID-19.

We present an asymptomatic 70-year-old man referred for an F-FDG PET/CT for initial staging of a Hodgkin lymphoma. F-FDG PET/CT showed bilateral cervical lymphadenopathy (stage II). Incidentally, the CT demonstrated bilateral ground-glass opacities with low-grade F-FDG activity. CT findings were suspicious for COVID-19 pneumonitis. The COVID-19 reverse transcriptase polymerase chain reaction (RT-PCR) examination result was negative. Given the high clinical suspicion for COVID-19, the patient was isolated and repeat RT-PCR was positive at 72 hours. RT-PCR may be falsely negative in early COVID-19 disease, even with positive CT findings.

Vulnerability index to COVID-19: Fortaleza, Brazil study case

The study proposes an index of vulnerability to the spread of COVID-19 using multivariate and geospatial analyses. Vulnerability was considered as a combination of exposure, susceptibility, and responsiveness of the population. The methodology consisted of six steps selection and grouping of variables;definition of indicators;normalization of the variables;weight calculation using principal component analysis;index calculation and normalization;and classification using Jenks Kmeans, Quantile, and Hclust techniques. The exposure of Fortaleza, Brazil, to COVID-19 was assessed by means of population density, number of subnormal and precarious housing, percentage of aged people per residence and proximity to bus terminals. The study integrates factors related to socioeconomic characteristics, public water supply and sanitation for the classification of census tracts in five levels of vulnerability. Most of them present high (Jenks and Quantile) and moderate (K-means and Hclust) vulnerability. The most vulnerable regions are in the South and West Zones of the city, where many subnormal agglomerates are located. The results can assist the development of coping strategies for the groups most exposed to the risks associated with COVID-19, as well as in the preparation for future public health crises. The methodology can be replicated in other cities and can be useful for public managers.