Traumatic and nontraumatic orthopaedic conditions are major contributors to global morbidity and account for the majority of life-years lived with disability worldwide. Additionally, the burden of ...musculoskeletal injuries has increased substantially over the past 3 decades. Unfortunately, in low and middle-income countries (LMICs), access to orthopaedic care is limited, leading to a disproportionate burden of disease. The Lancet Commission on Global Surgery has emphasized the urgent need for unified international commitment and research collaboration to achieve universal access to safe and affordable surgical care. However, conducting high-quality orthopaedic research in LMICs remains challenging as a result of disparities in training, access to resources, infrastructure, and equipment availability. Partnerships between high-income countries (HICs) and LMICs have emerged in recent decades as an effective approach to combatting some of these challenges. These partnerships aim to bridge the gaps by facilitating collaborative research and knowledge exchange. The establishment of successful partnerships requires a collaborative and reciprocal approach that starts with a clear understanding of mutual research aims and the availability of resources. Despite the potential benefits, various factors can make establishing such partnerships difficult. However, these partnerships can have a substantial impact in delivering quality orthopaedic education and research training, thus improving access to care in resource-limited environments. This paper represents the collaborative effort of multiple international academic orthopaedic surgeons with extensive experience in HIC-LMIC partnerships. Our aims were to outline the best practices for conducting orthopaedic research within these relationships and to provide guidance for future successful collaborations.
Prevention of fracture-related infection (FRI) remains a substantial challenge in orthopaedic trauma care. There is evolving evidence to support the use of local antibiotics for both the prevention ...and treatment of musculoskeletal infection. Local antibiotics can achieve higher local tissue concentrations with a lower risk of systemic complications compared to intravenously administered antibiotics. These antibiotics may be administered in powder or liquid form without carrier, or if sustained release is desired, using a carrier. Polymethylmethacrylate (PMMA), ceramics, and hydrogels are examples of antibiotic carriers. Unlike PMMA, ceramics and hydrogels have the advantage of not requiring a second surgery for removal. The VANCO trial supported the use of powdered vancomycin in high-risk fracture cases for the reduction of Gram-positive infections; although, data is limited. Future studies will evaluate the use of aminoglycoside antibiotics to address Gram-negative infection prevention. While theoretical concerns exist with the use of local antibiotics, available studies suggest local antibiotics are safe with a low-risk of adverse effects.
A biosimilar product needs to demonstrate biosimilarity to the originator reference product, and the quality profile of the latter should be monitored throughout the period of the biosimilar's ...development to match the quality attributes of the 2 products that relate to efficacy and safety. For the development of a biosimilar version of trastuzumab, the reference product, Herceptin®, was extensively characterized for the main physicochemical and biologic properties by standard or state-of-the-art analytical methods, using multiple lots expiring between March 2015 and December 2019. For lots with expiry dates up to July 2018, a high degree of consistency was observed for all the tested properties. However, among the lots expiring in August 2018 or later, a downward drift was observed in %afucose (G0+G1+G2). Furthermore, the upward drift of %high mannose (M5+M6) was observed in the lots with expiry dates from June 2019 to December 2019. As a result, the combination of %afucose and %high mannose showed 2 marked drifts in the lots with expiry dates from August 2018 to December 2019, which was supported by the similar trend of biologic data, such as FcγRIIIa binding and antibody-dependent cell-mediated cytotoxicity (ADCC) activity. Considering that ADCC is one of the clinically relevant mechanisms of action for trastuzumab, the levels of %afucose and %high mannose should be tightly monitored as critical quality attributes for biosimilar development of trastuzumab.
In low and middle-income countries (LMICs), there are often not enough orthopaedic surgeons to treat musculoskeletal conditions. International volunteerism is 1 way that the orthopaedic community ...seeks to meet this need. This study explored the opportunities available for orthopaedic surgeons to volunteer overseas as offered by nonprofit organizations in the United States and Canada.
A systematic internet search was conducted using 2 distinct search strategies. A website was considered a "hit" if it was that of a U.S. or Canada-based nonprofit, volunteer, or non-governmental organization that had opportunities for international orthopaedic volunteerism. Duplicate hits were eliminated to identify distinct organizations. Data regarding the work and geographical reach of the organization, as well as changes to its volunteer programs as a result of COVID-19, were extracted from each hit.
Of the 38 distinct organizations identified in the U.S. and Canada, the most common orthopaedic subspecialties represented were pediatrics (37%), hand (24%), and arthroplasty (18%). Foot and ankle (4 organizations; 11%), sports medicine (2 organizations; 5%), and oncology (1 organization; 3%) were the least represented subspecialities. The most common regions for volunteer trips included Latin America and the Caribbean, followed by West and East Africa. Twelve organizations (32%) were identified as having a religious affiliation. For most organizations, the trip duration was a minimum of 1 week. All volunteer organizations included operative or clinical experiences as part of their trips, and the majority of organizations (58%) reported that their trips included opportunities for training local surgeons. Many organizations (71%) reported having resumed trips after halting them during the COVID-19 pandemic.
Many opportunities exist for orthopaedic surgeons to volunteer their time and skills abroad. Future directions for the improvement of international volunteer efforts among the orthopaedic community could include expanding the number of existing volunteer opportunities and assessing the ethics, safety, efficacy, and longevity of these programs.
Despite efforts to advance clinical research through collaboration between Latin and North American partners, there remains persistent barriers to performing investigative work. To overcome these ...obstacles, a team of over 100 surgeon-leaders from 18 Latin American countries founded the Asociación de Cirujanos Traumatólogos de las Américas (ACTUAR). One of ACTUAR’s first major collaborative projects, initiated in 2018, was a prospective, observational, multicenter study evaluating quality of life after open tibia fracture management. The current study identified common barriers experienced during the initiation of this study, as exemplified through two sites in Mexico. The study aims to identify obstacles to proactively overcome these in future collaborative work.
Two research assistants from University of California, San Francisco and two research coordinators from Mexico were recruited to share their experiences, identify common barriers experienced during site enrollment and on-boarding for the ACTUAR open tibia study, and discuss possible solutions.
Barriers were organized into three categories: structural, logistical, and intrapersonal. Structural barriers included differences in patient populations and resources between private and public hospitals. Logistical barriers included ambiguous ethical review processes, internet availability, and low patient follow-up. Primary enrollment as a resident responsibility led to some intrapersonal barriers. Potential solutions were identified for each barrier and agreed upon by all collaborators.
Multiple barriers were identified by research personnel who initiated a prospective surgical clinical research study in Mexico. Through collaborative approaches, many potential solutions may help overcome these barriers and build locally led research capacity in Latin America.
Background: Studies have shown that resilience has a buffering effect on mental health problems. However, the influence of resilience on the impact on the Quality of Life (QoL) in the context of the ...COVID-19 pandemic has not been well documented. Objective: This study examined the influence of resilience on the COVID-19 impact on QoL among nursing students. Methods: A cross-sectional research design was utilized. Three hundred and forty-five students of a government-funded nursing school in the Philippines responded in the web-based survey. Data were gathered using two adopted instruments from 18 to 31 August 2020. Test for differences and correlational analyses were performed. Results: The COVID-19 pandemic had a moderate impact on the QoL of nursing students. The COVID-19 impact on QoL significantly varied with sex and the nearby presence of COVID-19 cases. Bivariate analysis revealed a significant moderate inverse relationship between psychological resilience and the impact of COVID-19 on QoL. Conclusion: Resilience has a protective influence on the impact on QoL concerning main areas of mental health in the context of the COVID-19 pandemic. Understanding the factors and developing interventions that build the resilience of students is a focal point of action for nursing schools.
Purpose
Although motorcycle accidents are a leading cause of limb injury in Uganda, little is known about injury care quality at regional hospitals. This study measured the incidence of clinical ...adverse events (CAEs) and identified associated treatment barriers surrounding motorcycle-related isolated limb injuries at a regional hospital.
Methods
A prospective descriptive study was conducted among patients with motorcycle-related isolated limb injuries at a Ugandan regional hospital between September 2017 and February 2018. Patients were surveyed upon admission and monitored throughout their course of treatment. Weight-bearing status and quality of life measures (EQ-5D) were assessed at four and 12 weeks.
Results
One hundred twenty-four participants enrolled. Of the total participants, 12% refused definitive treatment. Among 108 treated patients, six experienced CAEs: four wound infections, one amputation, and one death. At 12 weeks follow-up, the majority of patients had no difficulty with mobility, pain/discomfort, or self-care, but 51% endorsed challenges completing certain daily chores, and 40% of patients could ambulate without an assistive device with restoration of pre-fracture gait. Both longer hospital stays and poorer 12-week functional recovery were seen among patients sustaining open fracture (
p
< 0.001).
Conclusion
Treatment of isolated limb injuries at a Ugandan Regional Hospital was associated with minimal short-term CAEs. However, patients with more severe injuries may be at risk for delayed post-operative recovery. Future studies measuring long-term functional outcomes should be performed to better understand and optimize injury care in this population.
Abstract Objective To understand whether and how primary care providers and staff elicit patients' past experiences of healthcare discrimination when providing care. Data Sources/Study Setting Twenty ...qualitative semi‐structured interviews were conducted with healthcare staff in primary care roles to inform future interventions to integrate data about past experiences of healthcare discrimination into clinical care. Study Design Qualitative study. Data Collection/Extraction Methods Data were collected via semi‐structured qualitative interviews between December 2018 and January 2019, with health care staff in primary care roles at a hospital‐based clinic within an urban safety‐net health system that serves a patient population with significant racial, ethnic, and linguistic diversity. Principal Findings Providers did not routinely, or in a structured way, elicit information about past experiences of healthcare discrimination. Some providers believed that information about healthcare discrimination experiences could allow them to be more aware of and responsive to their patients' needs and to establish more trusting relationships. Others did not deem it appropriate or useful to elicit such information and were concerned about challenges in collecting and effectively using such data. Conclusions While providers see value in eliciting past experiences of discrimination, directly and systematically discussing such experiences with patients during a primary care encounter is challenging for them. Collecting this information in primary care settings will likely require implementation of multilevel systematic data collection strategies. Findings presented here can help identify clinic‐level opportunities to do so.
To estimate the indirect economic impact of tibial fractures and their associated adverse events (AEs) in Tanzania.
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.
The pGO-Tibia trial was conducted from November 2019 to August 2021 at the Muhimbili Orthopaedic Institute in Dar es Salaam, Tanzania.
One hundred adults with open tibial shaft fractures participated in this study.
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.
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.
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.
This study identified serious economic burden after tibial fractures, with significant differences in total indirect cost between those with and without an AE.
II.
•Surgeon-respondents in HICs and MICs in Latin America report differences in access to plastic surgeons and timing to definitive coverage of open tibia fractures.•In HICs, surgeons treat lower ...extremity proximal third, middle third, and distal third defects more commonly with free flaps. Surgeons in MICs treat these injuries more frequently with other methods, including fasciocutaneous flaps, local muscle flaps, or direct wound care.•Most orthopaedic surgeons reported limited access to all necessary soft-tissue surgical resources and tools, except Negative Pressure Wound Therapy (NPWT or Wound VAC).•Most orthopaedic surgeons in Latin America have not received soft-tissue flap coverage, skin grafting, or wound management training. The study’s findings demonstrate a strong interest in additional training.
This study examined soft-tissue coverage techniques of open tibia fractures, described soft-tissue treatment patterns across income groups, and determined resource accessibility and availability in Latin America.
A 36-question survey was distributed to orthopaedic surgeons in Latin America through two networks: national orthopaedic societies and the Asociación de Cirujanos Traumatólogos de las Américas (ACTUAR). Demographic information was collected, and responses were stratified by income groups: high-income countries (HICs) and middle-income countries (MICs).
The survey was completed by 469 orthopaedic surgeons, representing 19 countries in Latin America (2 HICs and 17 MICs). Most respondents were male (89%), completed residency training (96%), and were fellowship-trained (71%). Only 44% of the respondents had received soft-tissue training. Respondents (77%) reported a strong interest in attending a soft-tissue training course. Plastic surgeons were more commonly the primary providers for Gustilo Anderson (GA) Type IIIB injuries in HICs than in MICs (100% vs. 47%, p<0.01) and plastic surgeons were more available (<24 h of patient presentation to the hospital) in HICs than MICs (63% vs. 26%, p = 0.05), demonstrating statistically significant differences. In addition, respondents in HICs performed free flaps more commonly than in MICs for proximal third (55% vs. 10%, p<0.01), middle third (36% vs. 9%, p = 0.02), and distal third (55% vs. 10%, p<0.01) lower extremity wounds. Negative Pressure Wound Therapy (NPWT or Wound VAC) was the only resource available to more than half of the respondents. Though not statistically significant, surgeons reported having more access to plastic surgeons at their institutions in HICs than MICs (91% vs. 62%, p = 0.12) and performed microsurgical flaps more commonly at their respective institutions (73% vs. 42%, p = 0.06).
The study demonstrated that most orthopaedic surgeons in Latin America have received no soft-tissue training, HICs and MICs have differences in access to plastic surgeons and expectations for flap type and timing to definitive coverage, and most respondents had limited access to necessary soft-tissue surgical resources. Further investigation into differences in the clinical outcomes related to soft-tissue coverage methods and protocols can provide additional insight into the importance of timing and access to specialists.
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