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Objectives: To compare inpatient compliance with venous thromboembolism prophylaxis regimens. Design: A secondary analysis of patients enrolled in the ADAPT (A Different Approach to Preventing Thrombosis) randomized controlled trial. Setting: Level I trauma center. Patients/Participants: Patients with operative extremity or any pelvic or acetabular fracture requiring venous thromboembolism prophylaxis. Intervention: We compared patients randomized to receive either low molecular weight heparin (LMWH) 30 mg or aspirin 81 mg BID during their inpatient admission. Main Outcome Measurements: The primary outcome measure was the number of doses missed compared with prescribed number of doses. Results: A total of 329 patients were randomized to receive either LMWH 30 mg BID (164 patients) or aspirin 81 mg BID (165 patients). No differences observed in percentage of patients who missed a dose (aspirin: 41.2% vs LMWH: 43.3%, P = .7) or mean number of missed doses (0.6 vs 0.7 doses, P = .4). The majority of patients (57.8%, n = 190) did not miss any doses. Missed doses were often associated with an operation. Conclusions: These data should reassure clinicians that inpatient compliance is similar for low molecular weight heparin and aspirin regimens.

Introduction Patients who sustain orthopaedic trauma are at an increased risk of venous thromboembolism (VTE), including fatal pulmonary embolism (PE). Current guidelines recommend low-molecular-weight heparin (LMWH) for VTE prophylaxis in orthopaedic trauma patients. However, emerging literature in total joint arthroplasty patients suggests the potential clinical benefits of VTE prophylaxis with aspirin. The primary aim of this trial is to compare aspirin with LMWH as a thromboprophylaxis in fracture patients. Methods and analysis PREVENT CLOT is a multicentre, randomised, pragmatic trial that aims to enrol 12 200 adult patients admitted to 1 of 21 participating centres with an operative extremity fracture, or any pelvis or acetabular fracture. The primary outcome is all-cause mortality. We will evaluate non-inferiority by testing whether the intention-to-treat difference in the probability of dying within 90 days of randomisation between aspirin and LMWH is less than our non-inferiority margin of 0.75%. Secondary efficacy outcomes include cause-specific mortality, non-fatal PE and deep vein thrombosis. Safety outcomes include bleeding complications, wound complications and deep surgical site infections. Ethics and dissemination The PREVENT CLOT trial has been approved by the ethics board at the coordinating centre (Johns Hopkins Bloomberg School of Public Health) and all participating sites. Recruitment began in April 2017 and will continue through 2021. As both study medications are currently in clinical use for VTE prophylaxis for orthopaedic trauma patients, the findings of this trial can be easily adopted into clinical practice. The results of this large, patient-centred pragmatic trial will help guide treatment choices to prevent VTE in fracture patients. Trial registration number NCT02984384.

The impact of postoperative anti-TNF therapy on infectious complications following Crohn’s disease surgery remains controversial. Use of anti-TNF therapy 2–4 weeks postoperatively appears safe, but safety of use within 2 weeks is unknown. We sought to evaluate the effect of anti-TNF therapy initiated within 2 weeks of abdominal surgery in patients with Crohn’s disease. We conducted a retrospective review of adult Crohn’s disease patients undergoing abdominal surgery between 2004 and 2011. Infectious and non-infectious complications were compared between patients exposed to anti-TNF therapy within 2 weeks or between 2 and 4 weeks postoperatively and to those without exposure using chi-squared and regression analysis. Three hundred thirty-one abdominal surgeries were included; 241 were without anti-TNF exposure, 46 received postoperative anti-TNF within 2 weeks of surgery, and 44 received anti-TNF therapy 2–4 weeks after surgery. Patients who received anti-TNF therapy within 2 weeks of surgery, those initiated between 2 and 4 weeks of surgery, and those who did not receive anti-TNF therapy within 4 weeks of surgery had no significant difference in rates of infectious complications (22%, 32%, 33%, p = 0.332). Rates of non-infectious complications (4%, 9%, 14%, p = 0.143), mortality (0%, 0%, 3%, p = 0.105), hospital readmission (17%, 16%, 15%, p = 0.940), and reoperation (11%, 11%, 16%, p = 0.563) were also similar between groups. Use of early anti-TNF therapy within 2 weeks or between 2 and 4 weeks following abdominal surgery did not increase risk of postoperative surgical infections in Crohn’s patients.

Orthopedic trauma patients are often treated with venous thromboembolism (VTE) chemoprophylaxis with aspirin or low molecular weight heparin (LMWH) after discharge from their index admission, but adherence patterns are not known. We hypothesized that overall adherence would be moderate and greater with aspirin compared to LMWH.We conducted a randomized controlled trial of adult trauma patients with an operative extremity fracture or any pelvic/acetabular fracture requiring VTE prophylaxis. Patients were randomized to receive either LMWH 30 mg BID or aspirin 81 mg BID. Patients prescribed outpatient prophylaxis were contacted between 10 and 21 days after discharge to assess adherence measured by the validated Morisky Medication Adherence Scale (MMAS-8). Adherence scores were compared between the two treatment arms with similar results for intention-to-treat and as-treated analyses. As-treated multivariable logistic regression was performed to determine factors associated with low-medium adherence scores.One hundred fifty patients (64 on LMWH, 86 on aspirin) on chemoprophylaxis at time of follow-up completed the questionnaire. As-treated analysis showed that adherence was high overall (mean MMAS 7.2 out of 8, SD 1.5) and similar for the two regimens (LMWH: 7.4 vs. aspirin: 7.0, p = 0.13). However, patients on LMWH were more likely to feel hassled by their regimen (23% vs. 9%, p = 0.02). In a multivariable model, low-medium adherence was associated with taking LMWH as the prophylaxis medication (aOR 2.34, CI 1.06-5.18, p = 0.04), having to self-administer the prophylaxis (aOR 4.44, CI 1.45-13.61, p0.01), being of male sex (aOR 2.46, CI 1.10-5.49, p = 0.03), and of younger age (aOR 0.72 per additional 10 years of age, CI 0.57-0.91, p0.01).Overall post-discharge adherence with VTE prophylaxis was high. Several factors, including prophylaxis by LMWH, were associated with decreased adherence. These factors should be considered when managing patients and designing efficacy trials.Therapeutic, level II.

Background: A female patient with a history of stage IIB invasive lobular breast cancer presented with symptoms of partial small bowel obstruction and workup led to a presumptive diagnosis of Crohn’s disease. However, at the time of surgical intervention, she was found to have metastatic lobular breast cancer with carcinomatosis and metastases to the small and large intestines. Summary: Our patient presented at age 55 with intermittent nausea and vomiting, dyspepsia, altered bowel habits, and weight loss. She had a history of invasive lobular carcinoma of the right breast treated with right modified radical mastectomy followed by adjuvant chemoradiation and hormonal therapy 5 years earlier. She was thought to be in remission. Initial workup of her GI complaints was notable for thickening of the sigmoid colon and hepatic flexure on CT scan and stricturing and colitis in these areas on colonoscopy. Mucosal biopsies showed nonspecific active colitis. The patient was treated for a presumptive diagnosis of Crohn’s disease without significant improvement. She was eventually taken for surgery after presenting with a high-grade small bowel obstruction. On exploration, numerous additional small and large bowel strictures, some associated with intraluminal masses, were found and a small bowel resection and ileostomy performed. Pathology revealed metastatic invasive lobular breast carcinoma. Although isolated metastases to the bowel wall are rare, they have been reported secondary to a wide range of malignancies. Breast cancer, especially lobular carcinoma, is one of the most common tumors to metastasize to the GI tract and can present years after the primary cancer diagnosis. Therefore, the differential diagnosis for a patient with signs and symptoms of bowel obstruction and a history of lobular breast cancer should include metastatic disease. Conclusion: Metastatic cancer to the GI tract can mimic Crohn’s disease and should be on the differential in older patients with abdominal complaints, particularly those with a history of breast cancer.

Background The clinical course of patients with inflammatory bowel disease (IBD) after trauma is largely unknown. We sought to compare the clinical course of patients with IBD to those without. Methods We conducted a retrospective case-control study of adult patients admitted to a level-1 trauma center from January 1, 2008, through October 1, 2015. Seventy-five patients with IBD were identified. Cases were matched to controls by age, sex, injury severity, and mechanism using 4:1 propensity score-matching analysis. Injury characteristics, clinical course, and infectious and noninfectious complications were compared using bivariate and multivariate analysis. Results Participants had a mean age of 56 years and mean injury severity score of 15. Of the 75 cases, 44% had ulcerative colitis, 44% had Crohn’s disease, and 12% had undetermined type. More cases were on an immunosuppressant (19% vs 2%, P < 0.01) or steroids (8% vs 2%, P = 0.02) on admission compared with controls. More cases had prior abdominal surgery (P = 0.01). Cases had fewer brain injuries (P = 0.02) and higher admission Glasgow Coma Scale (P < 0.01) but required more neurosurgical intervention (P = 0.03). Cases required more orthopedic surgeries (P < 0.01) and more pain management consultations (P = 0.04). In multivariable analysis, IBD was associated with increased odds of operative intervention, pain management consultation, venous thromboembolism, and longer hospital stay (P < 0.05). Patients on immunosuppressants had increased odds of requiring surgery (P = 0.04), particularly orthopedic surgery (P < 0.01). Conclusions Baseline factors associated with inflammatory bowel disease may place patients at higher risk for surgery and complications after trauma.

Traumatic injury in the elderly is an emerging global problem with an associated increase in morbidity and mortality. This study sought to describe the epidemiology of elderly injury and outcomes in sub-Saharan Africa.We conducted a retrospective analysis of adult patients (≥ 18 years) with traumatic injuries presenting to the Kamuzu Central Hospital (KCH) in Lilongwe, Malawi, over 5 years (2009-2013). Elderly patients were defined as adults aged ≥65 years and compared to adults aged 18-44 and 45-64 years. We used propensity score matching and logistic regression to compare the odds of mortality between age groups using the youngest age group as the reference.42,816 Adult patients with traumatic injuries presented to KCH during the study period. 1253 patients (2.9 %) were aged ≥65 years with a male preponderance (77.4 %). Injuries occurred more often at home as age increased (25.3, 29.5, 41.1 %, p 0.001) and falls were more common (14.1, 23.8, 36.3 %, p 0.001) for elderly patients. Elderly age was associated with a higher proportion of hospital admissions (10.6, 21.3, 35.2 %, p 0.001). Upon propensity score matching and logistic regression analysis, the odds ratio of mortality for patients aged ≥65 was 3.15 (95 % CI 1.45, 6.82, p = 0.0037) compared to the youngest age group (18-44 years).Elderly trauma in a resource-poor area in sub-Saharan Africa is associated with a significant increase in hospital admissions and mortality. Significant improvements in trauma systems, pre-hospital care, and hospital capacity for older, critically ill patients are imperative.

Background Gut bacteria are strongly suspected to play a key role in the pathogenesis of Crohn's disease (CD). Studies have demonstrated alterations in the gut microbiota in this patient population. The purpose of this study was to characterize the gut microbiota of fistulizing perianal CD. Materials and Methods Stool and fistula samples were obtained from patients undergoing surgery for CD-related anorectal fistulae. Microbial compositions of matched stool and fistula samples were characterized using 16S rRNA gene profiling. The effect of sample type, patient gender, disease classification (Montreal A/B), disease activity (Harvey Bradshaw Index), antibiotic use, and presence of active proctitis on microbial composition was assessed. Results Samples were obtained from 18 patients. Bacteroides was the most abundant genera across all samples collected, followed by Streptococcus and Bifidobacterium. Bifidobacterium was present at significantly higher levels in fecal samples than fistula samples, whereas Achromobacter and Corynebacterium were present at significantly higher levels in fistula samples. Antibiotic, but not thiopurine or antitumor necrosis factor medication, exposure affected the gut microbial composition. Patient gender, disease classification, disease activity, and presence of active proctitis did not alter stool or fistula microbiota. Conclusions Our data show that the gut microbiota within CD-related anorectal fistulae is distinct from that in stool samples obtained from the same patients. We also observe a dysbiosis in patients treated with antibiotics compared with those not treated with antibiotics.

Data regarding who will require tracheostomy are lacking which may limit investigations into therapeutic effects of early tracheostomy. We performed an observational study of adult traumatic brain injury (TBI) patients requiring intensive care unit (ICU) admission for ≥ 72 h and mechanical ventilation for ≥ 24 h between January 2014 and December 2014 at a level 1 trauma center. Patients who had life-sustaining measures withdrawn were excluded. Multivariable logistic regression analyses were used to assess admission and inpatient factors associated with receiving a tracheostomy and to develop predictive models. Inpatient complications prior to day 7 were used to standardize data collection for patients with and without tracheostomy. Patients who received tracheostomy prior to day 7 were excluded from analysis. In total, 209 patients (78% men, mean 48 years old, median Glasgow Coma Scale score (GCS) 8) met study criteria with tracheostomy performed in 94 (45%). Admission predictors of tracheostomy included GCS, chest tube, Injury Severity Score, and Marshall score. Inpatient factors associated with tracheostomy included the requirement for an external ventricular drain (EVD), number of operations, inpatient dialysis, aspiration, GCS on day 5, and reintubation. Multiple logistic regression analysis demonstrated that the number of operation room trips (adjusted odds ratio [AOR], 1.75; 95% CI, 1.04–2.97; P = 0.036), reintubation (AOR, 8.45; 95% CI, 1.91–37.44; P = .005), and placement of an EVD (AOR, 3.48; 95% CI, 1.27–9.58; P = .016) were independently associated with patients undergoing tracheostomy. Higher GCS on hospital day 5 (AOR, 0.52; 95% CI, 0.40–0.68; P

The impact of postoperative anti-TNF therapy on infectious complications following Crohn's disease surgery remains controversial. Use of anti-TNF therapy 2-4 weeks postoperatively appears safe, but safety of use within 2 weeks is unknown.We sought to evaluate the effect of anti-TNF therapy initiated within 2 weeks of abdominal surgery in patients with Crohn's disease.We conducted a retrospective review of adult Crohn's disease patients undergoing abdominal surgery between 2004 and 2011. Infectious and non-infectious complications were compared between patients exposed to anti-TNF therapy within 2 weeks or between 2 and 4 weeks postoperatively and to those without exposure using chi-squared and regression analysis.Three hundred thirty-one abdominal surgeries were included; 241 were without anti-TNF exposure, 46 received postoperative anti-TNF within 2 weeks of surgery, and 44 received anti-TNF therapy 2-4 weeks after surgery. Patients who received anti-TNF therapy within 2 weeks of surgery, those initiated between 2 and 4 weeks of surgery, and those who did not receive anti-TNF therapy within 4 weeks of surgery had no significant difference in rates of infectious complications (22%, 32%, 33%, p = 0.332). Rates of non-infectious complications (4%, 9%, 14%, p = 0.143), mortality (0%, 0%, 3%, p = 0.105), hospital readmission (17%, 16%, 15%, p = 0.940), and reoperation (11%, 11%, 16%, p = 0.563) were also similar between groups.Use of early anti-TNF therapy within 2 weeks or between 2 and 4 weeks following abdominal surgery did not increase risk of postoperative surgical infections in Crohn's patients.

We sought to determine the outcome of suicidal hanging and the impact of targeted temperature management (TTM) on hanging-induced cardiac arrest (CA) through an Eastern Association for the Surgery of Trauma (EAST) multicenter retrospective study.We analyzed hanging patient data and TTM variables from January 1992 to December 2015. Cerebral performance category score of 1 or 2 was considered good neurologic outcome, while cerebral performance category score of 3 or 4 was considered poor outcome. Classification and Regression Trees recursive partitioning was used to develop multivariate predictive models for survival and neurologic outcome.A total of 692 hanging patients from 17 centers were analyzed for this study. Their overall survival rate was 77%, and the CA survival rate was 28.6%. The CA patients had significantly higher severity of illness and worse outcome than the non-CA patients. Of the 175 CA patients who survived to hospital admission, 81 patients (46.3%) received post-CA TTM. The unadjusted survival of TTM CA patients (24.7% vs 39.4%, p0.05) and good neurologic outcome (19.8% vs 37.2%, p0.05) were worse than non-TTM CA patients. However, when subgroup analyses were performed between those with an admission Glasgow Coma Scale score of 3 to 8, the differences between TTM and non-TTM CA survival (23.8% vs 30.0%, p = 0.37) and good neurologic outcome (18.8% vs 28.7%, p = 0.14) were not significant. Targeted temperature management implementation and post-CA management varied between the participating centers. Classification and Regression Trees models identified variables predictive of favorable and poor outcome for hanging and TTM patients with excellent accuracy.Cardiac arrest hanging patients had worse outcome than non-CA patients. Targeted temperature management CA patients had worse unadjusted survival and neurologic outcome than non-TTM patients. These findings may be explained by their higher severity of illness, variable TTM implementation, and differences in post-CA management. Future prospective studies are necessary to ascertain the effect of TTM on hanging outcome and to validate our Classification and Regression Trees models.Therapeutic study, level IV; prognostic study, level III.

The optimal approach of provider-initiated HIV testing and counseling (PITC) for inpatients in high-burden settings is unknown. We prospectively evaluated the implementation of task-shifting from clinician-referral to counselor-initiated PITC on the medical wards of Kamuzu Central Hospital, Malawi. The majority of patients (1905/3154, 60.4%) had an unknown admission HIV status. Counselors offered testing to 66.6% (1268/1905). HIV prevalence was 39.3%. Counselor-initiated PITC significantly increased HIV testing by 79% (643/2957 vs. 1228/3154), resulting in an almost 2-fold increase in patients with known HIV status (2447/3154 vs. 1249/3154) (both p

Background In the era of increased access to HIV testing and antiretroviral treatment (ART), the impact of HIV and ART status on inpatient mortality in Malawi is unknown. Methods We prospectively followed adult inpatients at Kamuzu Central Hospital medical wards in Lilongwe, Malawi, between 2011 and 2012, to evaluate causes of mortality, and the impact of HIV and ART status on mortality. We divided the study population into five categories: HIV-negative, new HIV-positive, ART-naive patients, new ART-initiators, and ART-experienced. We used multivariate binomial regression models to compare risk of death between categories. Results Among 2911 admitted patients the mean age was 38.5 years, and 50% were women. Eighty-one percent (81%) of patients had a known HIV status at the time of discharge or death. Mortality was 19.4% and varied between 13.9% (HIV-negative patients) and 32.9% (HIV-positive patients on ART ≤1 year). In multivariable analyses adjusted for age, sex and leading causes of mortality, being new HIV-positive (RR = 1.64 95% CI: 1.16–2.32), ART-naive (RR = 2.28 95% CI: 1.66–2.32) or being a new ART-initiator (RR = 2.41 95% CI: 1.85–3.14) were associated with elevated risk of mortality compared to HIV-negative patients. ART-experienced patients had comparable mortality (RR = 1.33 95% CI: 0.94–1.88) to HIV-negative patients. Conclusion HIV related mortality remains high among medical inpatients, especially among HIV-positive patients who recently initiated ART or have not started ART yet.

In resource-limited settings, identification of successful and sustainable task-shifting interventions is important for improving care.To determine whether the training of lay people to take vital signs as trauma clerks is an effective and sustainable method to increase availability of vital signs in the initial evaluation of trauma patients.We conducted a quasi-experimental study of patients presenting with traumatic injury pre- and post-intervention.The study was conducted at Kamuzu Central Hospital, a tertiary care referral hospital, in Lilongwe, Malawi.All adult (age ≥ 18 years) trauma patients presenting to emergency department over a six-month period from January to June prior to intervention (2011), immediately post-intervention (2012), 1 year post-intervention (2013) and 2 years post-intervention (2014).Lay people were trained to take and record vital signs.The number of patients with recorded vital signs pre- and post-intervention and sustainability of the intervention as determined by time-series analysis.Availability of vital signs on initial evaluation of trauma patients increased significantly post-intervention. The percentage of patients with at least one vital sign recorded increased from 23.5 to 92.1%, and the percentage of patients with all vital signs recorded increased from 4.1 to 91.4%. Availability of Glasgow Coma Scale also increased from 40.3 to 88.6%. Increased documentation of vital signs continued at 1 year and 2 years post-intervention. However, the percentage of documented vital signs did decrease slightly after the US-trained medical student and surgeon who trained the trauma clerks were no longer available in country, except for Glasgow Coma Scale. Patients who died during emergency department evaluation were significantly less likely to have vital signs recorded.The training of lay people to collect vital signs and Glasgow Coma Scale is an effective and sustainable method of task shifting in a resource-limited setting.

Despite the high prevalence of HIV in adults (11 %) in Malawi, testing among surgical patients is not routine. We examined the feasibility of universal opt-out HIV testing and counseling (HTC) on the surgical wards of Kamuzu Central Hospital in Lilongwe, Malawi, and sought to further delineate the role of HIV in surgical presentation and outcome.We reviewed HTC and surgical admission records from May to October 2011 and compared these data to data collected prospectively on patients admitted from November 2011 through April 2012, after universal HTC implementation.Prior to universal HTC, 270 of the 2,606 (10.4 %) surgical admissions were tested; 13 % were HIV-infected. After universal HTC implementation, HTC counselors reviewed 1,961 of the 2,488 admissions (79 %): 310 (16 %) had known status (157 seropositive, 153 seronegative) and 1,651 had unknown status (81 %). Among those with unknown status, 97 % (1,598, of 64 % of all admissions) accepted testing, of whom 9 % were found to be HIV-infected. Patients with longer lengths of stay (LOS) (mean = 11 vs. 5 days, p0.01) and those who underwent surgical intervention (odds ratio [OR] 2.5; confidence interval [CI] 2.0-3.1) were more likely to have a known status on discharge. HIV was more prevalence in patients with infection and genital/anal warts or ulcers and lower in trauma patients. HIV-positive patients received less surgical intervention (OR 0.69; CI 0.52-0.90), but there was no association between HIV status and length of stay or mortality.Universal opt-out HTC on the surgical wards was well accepted and increased the proportion of patients tested. High HIV prevalence in this setting merits implementation of universal HTC.

BACKGROUND No specific treatment is available for hanging-induced cardiac arrest (CA). We hypothesized that targeted temperature management (TTM) may improve the outcome of hanging-induced CA patients at hospital discharge. METHODS A retrospective chart review of our trauma registry from January 1999 to September 2015 was conducted to identify patients 18 years or older with hanging as their injury type. All TTMs were performed to achieve 32°C to 34°C for 24 hours. The survival and Cerebral Performance Category scores at hospital discharge were determined. RESULTS We identified 138 patients. Their average age was 32.1 ± 10.0 years; 81.3% were men, and 69.8% were white. The mortality rate was 15.2% (21 of 138). Overall, 79.7% (110 of 138) of the near-hanging patients did not sustain out-of-hospital CA (non-CA), and 1.8% of them (2 of 110) received TTM. All 110 non-CA patients survived to hospital discharge and 99.1% (109 of 110) had good neurologic outcome. The remaining 20.3% (28 of 138) of hanging patients suffered out-of-hospital CA; six of these patients were dead on arrival and thus excluded from further analysis. TTM was performed for 40.9% (9 of 22) of the remaining CA patients; 44.4% (4 of 9) of TTM CA patients survived to hospital discharge versus 23.1% (3 of 13) of non-TTM CA patients. There were no significant differences between the overall survival and patients discharged with good neurologic outcome between the TTM and non-TTM CA groups. CONCLUSION Non-CA near-hanging patients are more likely to have favorable outcome than the CA patients. Our study was not large enough to detect survival and neurologic outcome differences between the TTM and non-TTM CA groups. A multicenter retrospective study is underway to determine the impact of TTM on the outcome of hanging-induced CA patients. LEVEL OF EVIDENCE Therapeutic study, level IV; prognostic study, level IV.

Introduction Healthcare-associated infections are a significant health burden, and hand hygiene (HH) is an essential prevention strategy. World Health Organization (WHO) 2009 guidelines recommend washing hands during five moments of patient care; 1)before touching a patient; 2)before a clean procedure; 3)after body fluid exposure; and 4)after touching a patient or 5)patient surroundings. HH opportunities at these 5 moments are frequent and compliance is low (22-60%). Infection risk is particularly high in trauma patients, and HH compliance during active trauma resuscitation has yet to be evaluated. Materials and Methods Using video surveillance, all healthcare worker (HCW)-patient interactions for 30 patients were retrospectively reviewed for HH compliance according to WHO guidelines and glove use during initial resuscitation at a level-1 trauma center. Results 342 HCW-patient interactions and 1034 HH opportunities were observed. HH compliance with the WHO moments was 7% (71/1034) overall; 3% (10/375) before patient contact, 0% (0/178) before a clean procedure, 11% (2/19) after body fluid contact, 15% (57/376) after patient contact and 2% (2/86) after contact with the environment. Glove use was more common, particularly before (69%) and after (47%) patient contact and after body fluid contact (58%). No HH was observed before clean procedures, but HCW donned new gloves 75% of the time before bedside procedures. If donning/removing gloves was included with HH as compliant, compliance was 57% overall. Conclusion HH opportunities are frequent and compliance with WHO HH guidelines may be infeasible, requiring significant amounts of time that may be better spent with the patient during the golden hour of trauma resuscitation. In an era where more scrutiny is being applied to patient safety, particularly the prevention of inpatient infections, more research is needed to identify alternative strategies (e.g. glove use, prioritizing moments) that may more effectively promote compliance in this setting.

ObjectiveLimited evidence for the optimal venous thromboembolism (VTE) prophylaxis regimen in orthopaedic trauma leads to variability in regimens. We sought to delineate patient preferences towards cost, complication profile, and administration route (oral tablet vs. subcutaneous injection).DesignDiscrete choice experiment (DCE).SettingLevel 1 trauma center in Baltimore, USA.Participants232 adult trauma patients (mean age 47.9 years) with pelvic or acetabular fractures or operative extremity fractures.Primary and secondary outcome measuresRelative preferences and trade-off estimates for a 1% reduction in complications were estimated using multinomial logit modelling. Interaction terms were added to the model to assess heterogeneity in preferences.ResultsPatients preferred oral tablets over subcutaneous injections (marginal utility, 0.16; 95% CI: 0.11 - 0.21,PPConclusionsPatients preferred oral prophylaxis and were most concerned about risk of death from PE. Furthermore, the findings estimated the trade-offs acceptable to patients and heterogeneity in preferences for VTE prophylaxis.

Trauma scoring systems have been developed to assess injury severity and may have triage potential. We sought to evaluate the ability of the Kampala trauma score (KTS) to assess injury severity and its potential as an outcome predictive tool in Malawi. This is a prospective cohort study of trauma patients presenting to Kamuzu Central Hospital in 2012. We recorded admission KTS and Revised trauma score (RTS), emergency department disposition, and hospital length of stay (LOS) and survival. Logistic regression and ROC curve analyses were used to compare the KTS to the widely accepted RTS. 15,617 patients presented with trauma. 2,884 (18 %) were admitted, of which 2,509 (95 %) survived. The mean admission KTS was 14.5 ± 0.6, and RTS was 11.9 ± 0.3. For KTS and RTS, the odds of admission with each increment increase in score was 0.44 and 0.3, respectively. Similarly, odds of mortality is 0.48 and 0.36. Neither KTS (p = 0.96, ROC area 0.5) nor RTS (p = 0.25, ROC area 0.5) correlated significantly with hospital LOS. KTS and RTS performed equally well as predictors of mortality, but KTS was a better predictor of need for admission (KTS ROC area 0.62, RTS ROC area 0.55, p

Background Retirement migration from northern countries to southern countries is increasing in both Europe and North America, and retiree experiences will impact future migration and health services utilization. We therefore sought to describe the healthcare experiences and perceptions of retired U.S. citizens currently living in Mexico and Panama. Methods 46 retired U.S. citizens (23 per country) who had been hospitalized (61%) or had a chronic health condition (78%) in two regions per country with large communities of retired U.S. citizens were identified. Detailed semi-structured interviews were conducted to explore experiences with, attitudes toward, and costs of healthcare. Interviews were analyzed using quantitative and qualitative methods. Results Respondents averaged 68–70 years old, were well educated, had few physical dependencies, and had moderate incomes. They praised physician services as more personalized than in the U.S. and home care as inexpensive and widely available, expressed favorable opinions regarding outpatient and dental care, gave mixed ratings on hospital services, and expressed concerns about emergency services. Numerous concerns about health insurance were expressed, including the unavailability of Medicare and reductions in Tricare. Payment concerns and lack of data on local health providers made deciding where to obtain services challenging. Conclusions Retirees living abroad report dilemmas regarding healthcare choices, insurance availability, and quality of care. As this population segment grows, pressure will increase for policy and business solutions to existing medical care challenges.

Summary In many developing countries, including those of sub-Saharan Africa, care of the critically ill is poorly developed. We sought to elucidate the characteristics and outcomes of critically ill patients in order to better define the burden of disease and identify strategies for improving care. We conducted a cross sectional observation study of patients admitted to the intensive care unit at Kamuzu Central Hospital in 2010. Demographics, patient characteristics, clinical specialty and outcome data was collected for the 234 patients admitted during the study period. Older age and admission from trauma, general surgery or medical services were associated with increased mortality. The lowest mortality was among obstetrical and gynaecology patients. Use of the ventilator and transfusions were not associated with increased mortality. Patients with head injuries had the highest mortality rate. Rationing of critical care resources, using admitting diagnosis or scoring tools, can maximize access to critical care services in resource-limited settings. Furthermore, improvements of critical care services will be central to future efforts to reduce surgical morbidity and mortality and improving outcomes in all critically ill patients.

The mammalian oocyte-to-embryo transition, characterized by a period of transcriptional silence, is dependent on maternal RNAs and proteins produced during the growth phase of the oocyte. Signaling pathways control timely transcription and translation of RNA, as well as post-translational modification of proteins. The WNT/β-catenin pathway is clearly not active during preimplantation embryo development. However, alternative Wnt signaling pathways may play a role during early embryo development. This study describes the extensive expression, at the transcript and protein level, of receptors, ligands, and intracellular molecules known to play a role in WNT signaling, as well as those known to negatively regulate the canonical WNT/β-catenin pathway in developing oocytes and preimplantation embryos. This expression of a wide array of molecules involved in WNT signaling suggests that the alternative WNT pathways may be active during oogenesis and the oocyte-to-embryo transition. Developmental Dynamics 237:1099–1111, 2008. © 2008 Wiley-Liss, Inc.

The oocyte to embryo transition in metazoans depends on maternal proteins and transcripts to ensure the successful initiation of development, and the correct and timely activation of the embryonic genome. We conditionally eliminated the maternal gene encoding the cell adhesion molecule E-cadherin and partially eliminated the β-catenin gene from the mouse oocyte. Oocytes lacking E-cadherin, or expressing a truncated allele of β-catenin without the N-terminal part of the protein, give rise to embryos whose blastomeres do not adhere. Blastomere adhesion is restored after translation of protein from the wild-type paternal alleles: at the morula stage in embryos lacking maternal E-cadherin, and at the late four-cell stage in embryos expressing truncated β-catenin. This suggests that adhesion per se is not essential in the early cleavage stage embryos, that embryos develop normally if compaction does not occur until the morula stage, and that the zona pellucida suffices to maintain blastomere proximity. Although maternal E-cadherin is not essential for the completion of the oocyte-to-embryo transition, absence of wild-type β-catenin in oocytes does statistically compromise developmental success rates. This developmental deficit is alleviated by the simultaneous absence of maternal E-cadherin, suggesting that E-cadherin regulates nuclear β-catenin availability during embryonic genome activation.