Rising disease burden and health inequalities remain global concerns, highlighting the need for health systems strengthening with a sufficient and appropriately trained workforce. The current models ...for developing such a workforce are inadequate and newer approaches are needed. In this paper we describe a model for public health capacity building through online Global Learning, defined as “innovative, integrated, global opportunities for capacity building through online learning and shared experiences between and within Low- to Middle-Income Countries and High-Income Countries, in a continuous process that helps health care workers learn as they progress through their careers”. We demonstrate how two programmes, Peoples-uni and NextGenU.org , have implemented this model using a mix of low-cost and free online learning courses, a global community of volunteer tutors, mentors and peers, and appropriate high quality competence-based content.
Background
Fracture of the distal radius is a common clinical problem. A key method of surgical fixation is percutaneous pinning, involving the insertion of wires through the skin to stabilise the ...fracture.
Objectives
To evaluate the evidence from randomised controlled trials for the use of percutaneous pinning for fractures of the distal radius in adults.
Search methods
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (September 2006), the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and other databases, conference proceedings and reference lists of articles. No language restrictions were applied.
Selection criteria
Randomised or quasi‐randomised controlled clinical trials involving adults with a fracture of the distal radius, which compared percutaneous pinning with conservative treatment, or different aspects of percutaneous pinning.
Data collection and analysis
Two authors independently assessed and extracted data from the included trials. Some pooling of data was undertaken for one comparison.
Main results
Thirteen trials, involving 940 generally older adults with dorsally displaced and potentially or evidently unstable distal radial fractures, were included. Methodological weaknesses among these trials included lack of allocation concealment and inadequate outcome assessment. Factors affecting the applicability of trial evidence included inconsistent fracture classification, variations in outcome assessment and incomplete reporting.
Six heterogeneous trials compared percutaneous pinning with plaster cast immobilisation. Across‐fracture pinning, used in five trials, was associated with improved anatomical outcome and generally minor complications. There was some indication of similar or improved function in the pinning group. One quasi‐randomised trial found an excess of complications after Kapandji pinning.
Three trials compared different methods of pinning. Two trials found a higher incidence of complications after Kapandji fixation compared with two methods of across‐fracture fixation. The third trial provided inadequate evidence for modified Kapandji fixation versus Willenegger fixation.
Two small trials comparing biodegradable pins versus metal pins found a significant excess of complications associated with biodegradable material.
Two small trials compared plaster cast immobilisation for one week versus for six weeks after surgery. One trial found duration of immobilisation after trans‐styloid fixation did not have a significant effect on outcome. More complications occurred in the early mobilisation group after Kapandji pinning in the second trial.
Authors' conclusions
Though there is some evidence to support its use, the precise role and methods of percutaneous pinning are not established. The higher rates of complications with Kapandji pinning and biodegradable materials casts some doubt on their general use.
Early aggressive treatment of rheumatoid arthritis is associated with improved disease control, slower radiological progression and improved functional outcomes. Tumor necrosis factor blocking ...therapy is effective but there remain concerns about long-term risks. Combining disease-modifying antirheumatic drugs (DMARDs) is a widely used therapeutic alternative; however, there is uncertainty surrounding the most effective regimen. A popular combination is methotrexate plus sulfasalazine, but each of these DMARDs can also be used in combination with other DMARDs and in triple therapy regimens. However, wide variations in study size, design, steroid usage and approaches to combination therapy have made it difficult to form firm conclusions regarding their efficacy. Generally, combination therapy is well tolerated and associated with no significant increase in the rate of adverse events compared with monotherapy. Methotrexate-sulfasalazine, methotrexate-chloroquine, methotrexate-cyclosporin, methotrexate-leflunomide, methotrexate-intramuscular-gold and methotrexate-doxycycline are effective combination regimens. Triple DMARD therapy is better than various DMARD monotherapy and dual therapy regimens. Methotrexate and hydroxychloroquine may have synergistic anti-inflammatory properties. Clinical trial evidence to support the use of other methotrexate and sulfasalazine combinations is often weak or lacking. Further investigation is required to determine the most effective regimen and approach to combination therapy.
Evaluation of a complex and variable disease such as rheumatoid arthritis (RA) poses a challenge particularly over the medium to long term. A practical framework to evaluate clinically relevant ...outcomes over the long term is the "5D" approach of Fries, described in 1980. We describe the 20 year outcome in 52 survivors of a 123 patient cohort in terms of change in discomfort, disability, drug side effects, dollar costs, and deaths.
We studied 123 patients with RA allocated to their first disease modifying antirheumatic drug (DMARD) between 1977 and 1979. All were under the overall care of one physician over the 20 years and were maintained where possible taking a single DMARD. Baseline demographic variables, the Ritchie Articular Index (RAI), Lee functional index, and erythrocyte sedimentation rate (ESR) were initially recorded. The extent to which the demographic and disease variables contributed to need for joint replacement surgery was assessed. Therapies for comorbidity were also documented.
At cohort inception mean age was 50 years, RAI was 35, and median disease duration 5.5 years. F:M ratio was 90:33; 96% of patients were positive for rheumatoid factor (RF). Initial median ESR was 55 mm/h. At 20 years, 9 patients (7% of original cohort, 14% of survivors) were lost to followup and 62 (50%) had died. In the 52 survivors RAI, a surrogate for disability, showed a significant improvement (p < 0.0001), but disability measured by Lee functional index showed a deterioration (p = 0.018); 50% underwent joint replacement surgery. Initial ESR and mean ESR over the first 10 years of followup were significantly higher in those who required surgery. Nonsteroidal antiinflammatory drug (NSAID) use declined, but at least 2 deaths and 4 renal deaths that may have been related to therapy were attributed to NSAID use. No unexpected DMARD toxicity or mortality occurred. Concomitant therapy for comorbidity, in particular for cardiovascular disease, osteoporosis, and gastrointestinal disease, increased: more than 60% were on these therapies at 20 year followup.
Strategies to improve the outcome of RA in all dimensions should include: earlier referral for expert assessment; avoidance of NSAID gastrointestinal and nephrotoxicity; a more intensive effort to identify effective management of comorbidity and those likely to have a poor outcome. Such patients require sustained, intensive therapy to minimize later disability.
Purpose - The purpose of this paper is to describe the experiences of Manchester Primary Care Trust (PCT) of driving improvement in quality and patient safety as commissioners in the English National ...Health Service (NHS). After the PCT's establishment in late 2006, considerable work was undertaken to develop and promote the role of Commissioner as the custodian of standards of services for its resident population. This required engagement with internal PCT stakeholders and a range of external stakeholders locally, regionally and nationally. The authors' experience should be of interest in the UK, and beyond given that many health systems have, or are moving towards, a commissioner: provider model.Design methodology approach - This is a case study using self-reported observational approach.Findings - The authors' experience showed that commissioners can and should provide the leadership in driving quality improvements and patient safety, within their health systems. However, the challenges must not be underestimated, and the authors share some of the methods they used and lessons they learned.Research limitations implications - There is a considerable interest in promoting quality through better commissioning of health care services. However, there is limited research into the impact and effectiveness of using commissioning as a lever. Given that in the NHS, and elsewhere in the world, commissioning is seen as the organising principle for health systems, such research and evaluation should be a priority.Practical implications - This case study has valuable lessons for the new NHS and the findings are relevant to other health systems. There is a danger that the new NHS will repeat some of the mistakes of the past, and hopefully this case study can help avoid, or limit, the risks.Originality value - To the authors' knowledge there is no comparable piece of work, and the data findings have not been published or reported comprehensively before. The paper should be of value to not just the NHS but to health systems generally, since commissioning seems to be the prevailing model for organising them.
Wu previously raised awareness of the "second victim phenomenon," whereby HCWs experience serious functional impairment, with some leaving their profession and a few committing suicide. 1 During its ...annual conference in November, the British Association of Physicians of Indian Origin (BAPIO), passed a motion asking that suicides by HCWs while undergoing investigations should be treated as a "never event." The US poet and physician Williams Carlos Williams described a doctor as "one upon whom we set our hopes when ill and our dogs when well," and the way things are in the NHS many HCWs can identify with this. ...creating this new never event will go some way towards supporting HCWs and a long way towards improving patient safety.
In an attempt to increase global access to education about medical ethics, a free fully online course was developed on the Peoples-uni Open Online Courses site. Students came from 60 countries and ...were more likely to be medical practitioners, have come from the global North, and to have heard about the course through the web than other students enrolled in the Peoples-uni Open Online Courses site. Students scored high marks on the five quizzes. A third of the students gained a certificate of completion. Course feedback was overwhelmingly positive. Students stated that they learned the most from the lesson on professionalism, while other topics such as patient rights and autonomy, legal issues, and healthcare organisation and public health were also frequently mentioned. The course is an example of how open online courses can play a role in increasing awareness of medical ethics. Based on its analysis, the study identifies a need to attract interest in this area from low- and middle-income countries.
Background
Fracture of the distal radius is a common injury. A surgical treatment is external fixation, where metal pins inserted into bone on either side of the fracture are then fixed to an ...external frame.
Objectives
To evaluate the evidence from randomised controlled trials comparing different methods of external fixation for distal radial fractures in adults.
Search methods
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (June 2007), the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and other databases, conference proceedings and reference lists of articles. No language restrictions were applied.
Selection criteria
Randomised or quasi‐randomised controlled clinical trials which compared different methods of external fixation in adults with a distal radial fracture.
Data collection and analysis
All review authors independently performed study selection. Two authors independently assessed the included trials and performed data extraction.
Main results
Nine small trials involving 510 adults with potentially or evidently unstable fractures, were grouped into five comparisons. The interventional, clinical and methodological heterogeneity of trials precluded data pooling. Only one trial had secure allocation concealment.
Two trials comparing a bridging (of the wrist) external fixator versus pins and plaster external fixation found no significant differences in function or deformity. One trial found tendencies for more serious complications but less subsequent discomfort and deformity in the fixator group.
Three trials compared non‐bridging versus bridging fixation. Of the two trials testing uni‐planar non‐bridging fixation, one found no significant differences in functional or clinical outcomes; the other found non‐bridging fixation significantly improved grip strength, wrist flexion and anatomical outcome. The third trial found no significant findings in favour of multi‐planar non‐bridging fixation of complex intra‐articular fractures.
One trial using a bridging external fixator found that deploying an extra external fixator pin to fix the 'floating' distal fragment gave superior functional and anatomical results.
One trial found no evidence of differences in clinical outcomes for hydroxyapatite coated pins compared with standard uncoated pins.
Two trials compared dynamic versus static external fixation. One trial found no significant effects from early dynamism of an external fixator. The poor quality of the other trial undermines its findings of poorer functional and anatomical outcomes for dynamic fixation.
Authors' conclusions
There is insufficient robust evidence to determine the relative effects of different methods of external fixation. Adequately powered studies could provide better evidence.
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