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Objectives: Parkinson’s disease is the most common neurodegenerative disease. Combining levodopa with other drugs, including decarboxylase inhibitors (DCI) is its most effective treatment. Urinary tract infection (UTI) is the most common cause of hospitalization in Parkinson’s patients, making it crucial to find an appropriate treatment to reduce the incidence of this complication. This study aimed to investigate UTIs in Parkinson’s patients using levodopa with DCI supplements. Methods: In this systematic review and meta-analysis, databases such as PubMed, Scopus, Embase, Cochrane, and Web of Science were searched up to March 2024. Only randomized controlled trials involving Parkinson’s patients were included in the present study. Parkinson’s patients who used levodopa along with carbidopa or benserazide were considered the intervention group, while those who used levodopa with another drug were considered the control group. Results: Nine interventional studies were ultimately analyzed. The relative risk (RR) of UTI in patients taking DCI was 26% lower than those who did not (RR Treatment/Control = 0.74, 95% CI: 0.58-0.95, p = 0.019). Furthermore, observations at different times of follow-up showed that at 13-24 weeks and at > 24 weeks of treatment with DCI, there was a reduction in the incidence of UTI (RR = 0.68, 95% CI: 0.46-1.01 and RR = 0.77, 95% CI: 0.58-1.0, respectively). On the contrary, there was an increase of the risk of UTI in the first 12 weeks of treatment with DCI (RR = 1.11, 95% CI: 0.37-3.33). Conclusions: The results of this study indicated that using DCI drugs is associated with a reduced relative risk of developing UTIs. The beneficial effect of the drug showed after 12 weeks of treatment after an initial negative effect on the risk of UTI.

Seaweeds possess considerable potential for developing and enhancing pharmaceutical drugs because of their wide variety as abundant sources of numerous bioactive secondary metabolites, making them well-suited for developing and enhancing pharmaceutical drugs. This study evaluated the antioxidant, secondary metabolites, total phenolic content, and total flavonoid content of various crude extracts (methanol, ethanol) and their fractions (50 % and 70 %) of Sargassum polycystum. Fourier transform infrared (FT‐IR) analysis was also performed to identify the active chemical composition of the crude extracts. The results showed that various extracts contained varying concentrations of terpenoid, saponin, phlobatannin, cardiac glycosides, phenolic, and flavonoid. FT-IR analysis confirmed the presence of phenols, carboxylic acid, ketones, ethers, aromatics, amides, and sulfonates. 100 % methanolic extract contained the maximum concentrations of total phenols (80.13 mg of GAE/g) and total flavonoids (38.33 mg of quercetin/g). 100 % methanol extracts exhibited higher antioxidant activity in the DPPH assay (78.32 %, IC50 = 1.59 mg/ml) and ABTS assay (69.82 %, IC50 = 2.39 mg/ml). The bio-functional activity of crude extracts depended on their extract and concentration. The present study demonstrates that the macroalgae S. polycystum contains noteworthy secondary metabolites and natural antioxidants, indicating their potential utilization in various pharmacological and functional food applications.

Crossed-fused renal ectopia (CFRE) is a rare congenital anomaly where both kidneys are fused on the same side. We report a case of a 52-year-old male patient who presented with central abdominal pain associated with hematuria and dysuria, with a history of left open ureterolithotomy. Abdominal computed tomography (CT) showed an 18-mm left distal ureteric stone and a CFRE with a bilateral duplex-collecting system. Left ureteroscopy and laser lithotripsy with magnetic double-J stent insertion were carried out successfully, and the patient was discharged on the same day in fair general condition.

Emphysematous prostatic abscess (EPA) is a rare condition characterized by gas and abscess accumulation in the prostate. In this case report we report a successfully treated EPA with liver abscess due to Klebsiella pneumoniae in a 49-year-old man. He was admitted with abdominal pain and fever. Physical examination revealed tender, palpable resonance urinary bladder, and prostatic tenderness on rectal digital examination. High inflammatory markers were found. Abdominal computer tomography (CT) confirmed EPA. The patient was treated with broad-spectrum antibiotics, strict blood glucose control, suprapubic catheterization, and transurethral deroofing of the prostatic abscess. After three weeks patient discharged in good condition.

Opportunist pathogens Escherichia coli and Salmonella spp. enter into human body through consumption of drinking water, causes different gastrointestinal disorders like diarrhea, dysentery and water borne infections like cholera, typhoid etc.. This study was carried out to determine the microbial safety of drinking jar water and antimicrobial resistant pattern against Escherichia coli in jar water samples at Chittagong, Bangladesh. About 189 drinking jar water samples were collected from 63 water treatment plants and market store over a period of two months. Most probable number (MPN) test was done to detect the coliforms in drinking water samples. The MPN number was high (63) after 24 hours incubation. The test results showed that 41 (21%) water samples has presence of coliforms and 27 (14%) plant water samples contain E. coli. But unfortunately Salmonella Spp. was not found in any of the samples. Conformation test of E. coli were performed by Polymeric Chain Reaction (PCR). The E. coli isolates were susceptible to Enrofloxacin (100%), Cephradine (100%), and Gentamycin (92.59%) with an intermediate sensitivity to Amoxicillin (7.40%) and Ceftriaxone (3.70%). The organisms showed 81.48%, 74.02% and 70.30% resistance to Ampicillin, Colistinsulphate, and amoxicillin respectively. So bacteriological assessment of all water sources for drinking should be planned and conducted on regular basis for considering the public health significance of these zoonotic pathogen that are transmitted through drinking jar water. [ABSTRACT FROM AUTHOR]

Background: Black pepper (Piper nigrum) is mainly cultivated in tropical areas such as South India. It is known as a popular spice in all over the world. Although some studies have been carried out to determine the ingredients of black pepper Essential Oil (EO) cultivated in various regions of the world, but there is little data about some physicochemical characteristics of EO of black pepper cultivated in Chittagong, Bangladesh. Methods: Black peppers samples were collected from the local market of Chittagong city. Extraction of black pepper EO was carried out using Clevenger apparatus. Chemical compounds of EO obtained from the black pepper were determined by analytical gas chromatography/mass spectrometry. Some physicochemical characteristics of extracted EO were determined according to the standard methods. All experiments were carried out in triplicate. Results: The major components of black pepper EO were caryophyllene (19.12%), limonene (9.74%), and camphene (8.44%). The contents of moisture, dry matter, protein, fatty oil, ash, carbohydrate, and crude fiber in black pepper samples were determined as 2.20, 96.12, 12.66, 14.41, 12.49, 42.56, and 5.55%, respectively. Also, food energy value was measured as 349.66±0.44 g/calories. Refractive index, specific gravity, as well as optical rotation of EO samples were 0.8590, 1.476 at 30 °C, and -10.300, respectively. Conclusion: The EO of black pepper cultivated in Chittagong, Bangladesh revealed desirable physicochemical characteristics and could be applied in food industry. [ABSTRACT FROM AUTHOR]

Purpose: The lack of available guidelines for the management of prostatic abscess (PA) results in inconsistencies in its management. The most commonly used management modalities were conservative treatment with parenteral antibiotics alone, transrectal ultrasound-guided (TRUS) needle aspiration, or transurethral deroofing (TUD). The current study is a retrospective study and examines prostatic abscess cases treated by either one or more of the different modalities. We assess and compare presentation, diagnosis, management, and outcomes of prostatic abscess and we compare the outcomes of the three management modalities. Methods: We retrieved the records of all patients ( n = 23) admitted to the Urology department at Al Wakra hospital with the computed tomography (CT) diagnosis of prostatic abscess from January 2013 to March 2018. Data collected included demographic, clinical, laboratory, and imaging findings, as well as management modality, duration of hospital stay, duration of follow up, outcome, and recurrence. Results: A total of nine (39.1%) patients had conservative treatment only; eight (34.8%) had TUD, and six (26.1%) had TRUS needle aspiration. The mean age was 52.7 years. Lower urinary tract symptoms and fever were the most common presentations (95.7% and 82.6%, respectively). CT scan of the abdomen and pelvis with contrast was undertaken for all patients and it showed that multiple abscesses were observed in 14 (60.9%) cases. The overall mean hospital stay was 8.45 days (range 2–21 days). We observed no recurrences for patients treated conservatively or those who undertook TUD, but three patient (50%) recurrences were noted in TRUS aspiration patients. There was no mortality across the sample. Conclusion: Early diagnosis of prostatic abscess and prompt management may have decreased the morbidity and mortality. Conservative management can succeed in subcentimeter abscesses but TUD is the definite therapy for large and multiloculated abscess. TRUS aspiration does have a role in treatment, but it has higher recurrence and longer hospital stay.

The aim of this paper is to localize the fugitive leaks from the above ground facilities of the existing system of Titas Gas (TG) after developing mathematical model for fugitive emission. Soap screening techniques and Gasurveyor 500 series instrument were used in this study for detecting potential leaks. Leaked gas was quantified using either Hi-Flow gas sampler or bagging measurements system. The results show that the respective potential gas leaking point of City Gate Station (CGS), commercial Regulating and Metering Station (RMS), industrial RMS, residential RMS and Town Bordering Station (TBS)/ District Regulating Station (DRS) are scrubber dump valve (average leak rate 217.00 L/min), insulating point (average leak rate 4.04 L/min), tube fitting connector (average leak rate 8.00 L/min), connector (average leak rate 1.55 L/min) and pressure relief valve (average leak rate 437.92 L/min). Fugitive methane emission can be reduced by stopping leaks of fittings or components having high KLeak value.

Summary Whether intermediate TCR (TCRint) cells and natural killer T (NKT or NK1.1+TCRint) cells are extrathymically generated remains controversial. This arises from the fact that there are few of these T cells in athymic nude mice and neonatally thymectomized mice. However, when athymic mice were provided with appropriate microenvironments or stimulation, many TCRint cells (mainly NK1.1-) were found to arise in the liver. NKT cells are known to be positively selected by monomorphic major histocompatibility complex (MHC) -like antigens (e.g. CD1d). This is true even if they are CD4+. In other words, a MHC class I-like antigen is restricted to CD4 antigen. This rule is somewhat different from that seen in conventional T cells (i.e. the restriction of class II with CD4 and that of class I and CD8). In the case of NK1.1-TCRint cells, they were selected by polymorphic MHC antigens, but their MHC restriction to CD4 or CD8 antigen was incomplete. This was revealed by experiments of bone marrow transfer with class I (bm 1) or II (bm 12) disparity. Depending on the disparity, a unique cytokine profile in sera was detected. These results suggest that the development of T lineage lymphocytes and MHC restriction to CD4 and CD8 might have occurred in parallell as a phylogenic event, and that NK1.1- extrathymic T cells (i.e. NK1.1-TCRint) are at an intermediate position between NKT cells and conventional T cells in phylogeny. [ABSTRACT FROM AUTHOR]

Recurrent testicular torsion after previous orchiopexy is rare and needs high index of suspension to avoid misdiagnosis and delayed management. This case showed that this diagnosis can occur even when the testis is still fixed to the scrotal wall. A 31-year-old male who had previous testicular fixation for testicular torsion with a single stitch to the lower pole before 6 years presented with recurrent testicular torsion and missed diagnosis. This case confirm that recurrent testicular torsion after previous fixation should be included in the differential diagnosis of acute scrotum and emphasis on the testicular fixation with nonabsorbable suture in at least two points to prevent recurrent torsion.

Introduction: Open tibia fractures are some of the most common types of Orthopedics injuries in low- and middle-income countries (LMICs). In Tanzania, open tibia fractures are treated either conservatively by prolonged cast or surgically by external fixation (EF) or intramedullary nail (IMN) when available. The cost of treatment and amount of time patients spend away from work are major economic concerns with prolonged casting and EF. The goal of this study was to determine the cost effectiveness of IMN versus EF in the treatment of open diaphyseal tibia fractures at Muhimbili Orthopaedic Institute (Dar es Salaam, Tanzania). Methods: This is a prospective randomized control study conducted of patients with a closeable AO/OTA 42 open diaphyseal tibia fracture. The patients underwent surgical fixation with either IMN or EF at Muhimbili Orthopaedic Institute (MOI), and were followed up at 2, 6, and 12 weeks postoperatively. A micro-costing method was used to estimate the fixed and variable costs of IMN and EF of the open diaphyseal tibial fracture. Results: The mean total cost per patient was lower for the IMN group ($425.8 ± 38.4) compared to the EF group ($559.6 ± 70.5, p

Background: Little is known about the quality of orthopaedic investigations conducted in low- and middle-income countries (LMICs). Academic collaboration is one model to build research capacity and improve research quality. Our study aimed to determine (1) the quality of clinical orthopaedic research conducted in LMICs, (2) the World Bank Regions and LMICs that publish the highest quality studies, (3) the pattern of collaboration among investigators and (4) whether academic collaboration between LMIC and non-LMIC investigators is associated with studies that have higher levels of evidence. Methods: Orthopaedic studies from 2004 to 2014 conducted in LMICs were extracted from multiple electronic databases. The World Bank Region, level of evidence and author country-affiliation were recorded. Collaboration was defined as a study that included an LMIC with non-LMIC investigator. Results: There were 958 studies that met inclusion criteria of 22,714 searched. Ninety-seven (10.1%) of included studies achieved Level 1 or 2 evidence, but case series (52.3%) were the most common. Collaboration occurred in 14.4% of studies and the vast majority of these (88.4%) were among academic institutions. Collaborative studies were more likely to be Level 1 or 2 (20.3% vs. 8.4%, p

Abstract Background A recently published meta-analysis comparing metallic staples to sutures in orthopaedic procedures revealed three fold increase in risk for infection in stapled wounds. The studies included in the meta-analysis are at risk of bias due to experimental design limitations. A large randomized controlled trial is proposed to direct orthopaedic surgeons in their choice of wound closure material. Methods/Design A parallel group randomized controlled trial with institutional review board approval will be conducted. Patients will be randomized intraoperatively to have skin wounds closed with sutures or staples. Dressings will be used to maintain blinding outcome assessors. The primary outcome measure will be a composite all-cause wound complication outcome measure composed of: infection, wound drainage, wound necrosis, blistering, dehiscence, suture abscess and material sensitivity reaction. An independent review board blinded to treatment assignment will adjudicate suspected complications based on clinical data. All deceased patients will also be reviewed. An interim analysis of complications will take place after half of the patients have been recruited. All data will be analyzed by a blinded statistician. Dichotomous primary and secondary outcome measures will be analyzed using the Chi-squared statistic. Continuous outcome measures will be analyzed using Student's t-test. Subgroup analysis will compare infection rates using sutures versus staples in each anatomic area (upper extremity, pelvis/acetabulum, hip/femur, knee, ankle). A further subgroup analysis will be conducted comparing trauma patients to elective surgery patients. Non-infected revision surgery will also be compared to primary surgery. Discussion Wound closure material is an afterthought for many orthopaedic surgeons. The combined results of several comparative trials suggests that the choice of wound closure materials may have an impact on the rate of surgical site infections. However, the strength of the evidence is poor given the heterogeneity of the methods employed in previous studies. The following study protocol aims to guide surgeons in their choice of wound closure material by determining if there is a difference in complication rates in sutured and stapled wounds. Trial Registration This trial was registered at ClinicalTrials.gov under the identifier NCT01146236 (registered June 14, 2010)

This research has evaluated the MPs distribution, characteristics, and potential threats of MPs in surface water and sediments from Hatiya Island. The results showed that the abundance of MPs was 139 ± 44 items/m 3 in surface water and 493 ± 80 items/kg dw in sediments, indicating higher levels of MPs contamination in sediment samples. Fibers were the predominant kind of microplastics, and microscopic sizes (0.3-1.5 mm) MPs were generally more frequent and largely present in both the surface water and sediments. Fourier-transform infrared spectroscopy (FTIR) confirmed that polyethylene terephthalate was the major polymer component of microplastics in surface water, whereas polyethylene was the most abundant polymer in sediments. MPs contamination risk was examined based on multiple risk assessment models. Nemerow pollution index (NPI) and pollutant load index (PLI) show minimal pollution levels of MPs. But potential hazard index (PHI), potential ecological risk factor (Er), and potential ecological risk index (RI), indicate severe MPs contamination due to the presence of polyurethane, polycarbonate, polyvinyl chloride, epoxy that were hazardous MPs and exhibited a critical concern for MPs risk. These statistics will help to understand the environmental difficulties generated by MPs and which hazard is waiting for mankind in the future., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

The thyroid eye disease (TED) of Graves disease is associated with high titers of stimulating TSH receptor antibodies, retro-orbital inflammation, fibroblast release of cytokines and chemokines, and adipogenesis, which in turn leads to proptosis, muscle fibrosis, and dysfunction. Part of this scenario is the induction of fibroblast proliferation and autophagy secondary to synergism between the TSH receptor (TSHR) and the insulin-like growth factor-1 receptor (IGF-1R). While TED is well associated with thyroid-stimulating antibodies to the TSHR, which is also well expressed on fibroblasts, in fact the TSHR reactome has a variety of TSHR antibodies with varying biological activity. Therefore, we have now evaluated the possible role of neutral TSHR antibodies (N-TSHR-mAbs), directed at the hinge region of the TSHR, which do not induce cell proliferation but are known to have effects on multiple proteins in thyroid cells including stress-related signaling molecules. We examined the consequences of an N-TSHR-mAb acting on TSHR-expressing fibroblasts and found marked cell stress, which initiated signaling pathways involving inflammasome activation. This response ended in widespread cell death by pyroptosis through activation of caspase 8 and gasdermin D. Hence, not only can stimulating TSHR autoantibodies influence TED inflammation but the N-TSHR antibodies, representing more of the reactome, may also exaggerate the retro-orbital inflammatory response seen in TED., (Published by Oxford University Press on behalf of the Endocrine Society 2024.)

Objectives: Open tibia fractures are associated with substantial morbidity and impact on quality of life. Despite increasing incidence in low-resource settings, most open tibia fracture research comes from high-resource settings. This study aimed to assess the impact of socioeconomic status on treatment modality and evaluate predictors of health-related quality of life following open tibia fractures in Ghana., Design: A single-center prospective observational study was conducted in Kumasi, Ghana, from May 2020 to April 2022. Adults with open tibial shaft fractures presenting within 2 weeks of injury were eligible. Demographics, comorbidities, socioeconomic factors, and hospital course were collected at enrollment. Follow-up was scheduled at 8, 12, 26, and 52 weeks. A telephone survey assessing reasons for loss to follow-up was initiated on enrollment completion., Results: A total of 180 patients were enrolled. Most patients were employed before injury (79.9%), had government insurance (67.2%), and were from rural areas (59.4%). Fracture classification was primarily Gustilo-Anderson type 3A (49.1%). No relationship between socioeconomic predictors and treatment modality was identified. The largest barriers to follow-up were preference for bonesetter treatment (63.1%), treatment cost (48.8%), and travel cost (29.8%). Of the lost to follow-up patients contacted, 67 (79.8%) reported receiving traditional bonesetter care. Reasons for seeking traditional bonesetter care included ease of access (83.6%), lower cost (77.6%), and familial influence (50.7%)., Conclusion: No association was identified between socioeconomic predictors and choice of treatment. Bonesetter treatment plays a substantial role in the care of open tibia fractures in Ghana, largely because of ease of access and lower cost., Competing Interests: The authors have no conflict of interest to report., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Orthopaedic trauma remains a leading cause of patient morbidity, mortality, and global health care burden. Although significant advances have been made in the diagnosis, treatment, and rehabilitation of these injuries, complications such as malunion, nonunion, infection, disuse muscle atrophy and osteopenia, and incomplete return to baseline function still occur. The significant inherent clinical variability in fracture care such as differing patient demographics, injury patterns, and treatment protocols make standardized and replicable study, especially of cellular and molecular based mechanisms, nearly impossible. Hence, the scientists dedicated to improving therapy and treatments for patients with orthopaedic trauma rely on preclinical models. Preclinical models have proven to be invaluable in understanding the timing between implant insertion and bacterial inoculation on the bioburden of infection. Posttraumatic arthritis (PTOA) can take years to develop clinically, but with a porcine pilon fracture model, posttraumatic arthritis can be reliably induced, so different surgical and therapeutic strategies can be tested in prevention. Conversely, the racehorse presents a well-accepted model of naturally occurring PTOA. With preclinical polytrauma models focusing on chest injury, abdominal injury, multiple fractures, and/or head injury, one can study how various injury patterns affect fracture healing can be systemically studied. Finally, these preclinical models serve as a translational bridge to for clinical application in human patients. With selection of the right preclinical model, studies can build a platform to decrease the risk of emerging technologies and provide foundational support for therapeutic clinical trials. In summary, orthopaedic trauma preclinical models allow scientists to simplify a complex clinical challenge, to understand the basic pathways starting with lower vertebrate models. Then, R&D efforts progress to higher vertebrate models to build in more complexity for translation of findings to the clinical practice., Competing Interests: The authors report no conflict of interest., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Objectives: To estimate the indirect economic impact of tibial fractures and their associated adverse events (AEs) in Tanzania., Design: A secondary analysis of the pilot Gentamicin Open (pGO)-Tibia randomized control trial estimating the indirect economic impact of suffering an AE, defined as a fracture-related infection (FRI) and/or nonunion, after an open tibial fracture in Tanzania., Setting: The pGO-Tibia trial was conducted from November 2019 to August 2021 at the Muhimbili Orthopaedic Institute in Dar es Salaam, Tanzania., Patients/participants: One hundred adults with open tibial shaft fractures participated in this study., Intervention: Work hours were compared between AE groups. Cost data were analyzed using a weighted-average hourly wage and converted into purchasing power parity-adjusted USD., Main Outcome Measurements: Indirect economic impact was analyzed from the perspective of return to work (RTW), lost productivity, and other indirect economic and household costs. RTW was analyzed using a survival analysis., Results: Half of patients returned to work at 1-year follow-up, with those experiencing an AE having a significantly lower rate of RTW. Lost productivity was nearly double for those experiencing an AE. There was a significant difference in the mean outside health care costs between groups. The total mean indirect cost was $2385 with an AE, representing 92% of mean annual income and an increase of $1195 compared with no AE. There were significantly more patients with an AE who endorsed difficulty affording household expenses postinjury and who borrowed money to pay for their medical expenses., Conclusions: This study identified serious economic burden after tibial fractures, with significant differences in total indirect cost between those with and without an AE., Level of Evidence: II., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Effective nonunion and bone defect management requires consideration of multiple potential contributing factors including biomechanics, biology, metabolic, and patient factors. This article reviews these factors as well as several potential nonunion or bone defect treatments including bone grafts, bone graft substitutes, the induced membrane technique, and distraction osteogenesis. A summary of these concepts and guidelines for an overall approach to management are also provided., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Background: The rate of open tibia fractures is rapidly increasing across the globe due to a recent rise in road traffic accidents, predominantly in low- and low-middle-income countries. These injuries are orthopedic emergencies associated with infection rates as high as 40% despite the use of systemic antibiotics and surgical debridement. The use of local antibiotics has shown some promise in reducing the burden of infection in these injuries due to increasing local tissue availability; however, no trial has yet been appropriately powered to evaluate for definitive evidence and the majority of current studies have taken place in a high-resource countries where resources and the bio-burden may be different., Methods: This is a prospective randomized, masked, placebo-controlled superiority trial designed to evaluate the efficacy of locally administered gentamicin versus placebo in the prevention of fracture-related infection in adults (age > 18 years) with primarily closeable Gustillo-Anderson class I, II, and IIIA open tibia fractures. Eight hundred ninety patients will be randomized to receive an injection of either gentamicin (treatment group) or saline (control group) at the site of their primarily closed open fracture. The primary outcome will be the occurrence of a fracture-related infection occurring during the course of the 12-month follow-up., Discussion: This study will definitively assess the effectiveness of local gentamicin for the prevention of fracture-related infections in adults with open tibia fractures in Tanzania. The results of this study have the potential to demonstrate a low-cost, widely available intervention for the reduction of infection in open tibia fractures., Trial Registration: Clinicaltrials.gov NCT05157126. Registered on December 14, 2021., (© 2023. The Author(s).)

Randomized controlled trials are the gold standard to establishing causal relationships in clinical research. However, these studies are expensive and time consuming to conduct. This article aims to provide orthopaedic surgeons and clinical researchers with methodology to optimize inference and minimize bias in observational studies that are often much more feasible to undertake. To mitigate the risk of bias arising from their nonexperimental design, researchers must first understand the ways in which measured covariates can influence treatment, outcomes, and missingness of follow-up data. With knowledge of these relationships, researchers can then build causal diagrams to best understand how to control sources of bias. Some common techniques for controlling for bias include matching, regression, stratification, and propensity score analysis. Selection bias may result from loss to follow-up and missing data. Strategies such as multiple imputation and time-to-event analysis can be useful for handling missingness. For longitudinal data, repeated measures allow observational studies to best summarize the impact of the intervention over time. Clinical researchers familiar with fundamental concepts of causal inference and techniques reviewed in this article will have the power to improve the quality of inferences made from clinical research in orthopaedic trauma surgery., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Background: Open tibial fractures have a high risk of infection that can lead to severe morbidity. Antibiotics administered locally at the site of the open wound are a potentially effective preventive measure, but there are limited data evaluating aminoglycoside antibiotics. The objective of this study was to assess the feasibility of a clinical trial to test the efficacy of local gentamicin in reducing the risk of fracture-related infection after open tibial fracture., Methods: This study is a single-center, pilot, masked, randomized controlled trial conducted at the Muhimbili Orthopaedic Institute. Participants were randomized intraoperatively after wound closure to receive gentamicin solution or normal saline solution injected at the fracture site. Follow-ups were completed at 2 weeks, 6 weeks, 3 months, 6 months, 9 months, and 1 year postoperatively. The primary feasibility outcomes were the rate of enrollment and retention. The primary clinical outcome was the occurrence of fracture-related infection., Results: Of 199 patients screened, 100 eligible patients were successfully enrolled and randomized over 9 months (11.1 patients/month). Complete data were recorded at baseline and follow-up for >95% of cases. The rate of follow-up at 6 weeks, 3 months, 6 months, 9 months, and 1 year were 70%, 68%, 69%, 61%, and 80%, respectively. There was no difference in adverse events or any of the measured primary and secondary outcomes., Conclusion: This pilot study is among the first to evaluate locally administered gentamicin in open tibial fractures. Results indicate a rigorous clinical trial with acceptable rates of enrollment and follow-up to address this topic is possible in this setting., Competing Interests: The authors have no conflicts of interest to disclose, (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Background: The burden of disability because of traumatic limb amputation, particularly transfemoral amputation (TFA) is disproportionately carried by low- and middle-income countries. The need for improved access to prosthesis services in these settings is well-documented, but perspectives on the burden imposed by TFA and the challenges associated with subsequent prosthesis provision vary among patients, caregivers and healthcare providers., Objectives: To examine the burden of TFA and barriers to prosthesis provision as perceived by patient, caregiver and healthcare professional, at a single tertiary referral hospital in Tanzania., Method: Data were collected from five patients with TFA and four caregivers recruited via convenience sampling, in addition to 11 purposively sampled healthcare providers. All participants participated in in-depth interviews regarding their perceptions of amputation, prostheses and underlying barriers to improving care for persons with TFA in Tanzania. A coding schema and thematic framework were established from interviews using inductive thematic analysis., Results: All participants noted financial and psychosocial burdens of amputation, and perceived prostheses as an opportunity for return to normality and independence. Patients worried about prosthesis longevity. Healthcare providers noted significant obstacles to prosthesis provision, including infrastructural and environmental barriers, limited access to prosthetic services, mismatched patient expectations and inadequate coordination of care., Conclusion: This qualitative analysis identifies factors influencing prosthesis-related care for patients with TFA in Tanzania which are lacking in the literature. Persons with TFA and their caregivers experience numerous hardships exacerbated by limited financial, social and institutional support., Contribution: This qualitative analysis informs future directions for research into improving prosthesis-related care for patients with TFA in Tanzania., Competing Interests: The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article., (© 2023. The Authors.)

Introduction: An increasing number of fellowship-trained orthopaedic trauma surgeons are working in non-Level I centers. This study aimed to examine trends of management of complex orthopaedic trauma in Level I centers versus non-Level I centers and its potential effect on patient outcomes., Methods: Data from the National Trauma Data Bank from 2008 to 2017 were analyzed. Non-Level I to Level I center ratios for complex fractures and complication rates, median hours to procedure for time-sensitive fractures, and uninsured/underinsured rates of Level I and non-Level I centers were recorded., Results: Three hundred one thousand patients were included. A statistically significant downward trend was identified in the percent of all complex orthopaedic trauma at Level I centers and per-hospital likelihood of seeing a complex orthopaedic fracture in a Level I versus non-Level I hospital. Per-hospital complication rates were consistently lower in non-Level I hospitals after controlling for injury severity and payer mix. Time-sensitive fractures were treated earlier in non-Level I centers., Discussion: This study demonstrates a reduction of complex trauma treatment in Level I centers that did not translate to adverse effects on patient outcomes. Policymakers should notice this trend to ensure the continued quality of orthopaedic trauma training and maintenance of expertise in complex fracture management., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

International observerships are one of many efforts aimed at addressing disparities in orthopaedic trauma care globally. However, their impact on visiting surgeons and their home countries, as well as the challenges faced by participating surgeons, are not well-documented., Methods: A survey was distributed to overseas surgeons who participated in an orthopaedic trauma observership from 2009 to 2020. Surgeons were identified through North American institutions previously recognized by the authors as having hosted international observerships. Information gathered included participant demographics, details of and perceived impact of the observership, and barriers faced before, during, and after the program. Responses from 148 international surgeons (ISs) from 49 countries were analyzed., Results: Sixty percent of observerships were at academic programs, 57% lasted 1-3 months, and 60% were self-funded. Participants identified cost and housing as primary barriers. After completing their observership, lack of funding, equipment and support staff, and excessive workload prevented participants from implementing changes at their clinical practice. Most observers believed that they gained relevant clinical (89%) and surgical knowledge (67%) and developed a professional network of North American hosts (63%). The most common suggested changes to the observership were greater hands-on experience in the operating room and structured goal setting relevant to the visiting surgeon., Conclusions: Visiting surgeons find North American orthopaedic trauma observerships helpful in improving their surgical and clinical skills. However, financial constraints and resource limitations at their clinical practice and limited operative experience during the observership present barriers to maximizing this clinical experience. To enhance the relevance of clinical observerships for ISs and impact global orthopaedic trauma care, the unique needs and challenges facing ISs must be addressed., Level of Evidence: IV-Cross-Sectional Study., Competing Interests: The authors report no conflict of interest., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)