1445 Using BOAST Guidelines to Boost Standards: An Audit of Adherence to BOAST Open Fracture Guidelines

Aim

Open fractures require prompt management and appropriate infrastructure is required to deliver optimal care. The BOAST Open Fracture guidelines (2017) set out best practice in their management and advocate a combined Orthoplastics approach.

Method

All patients with open tibial fractures who presented to or were referred to our hospital from January 2018 - March 2020 were included in our audit. The standard used was the BOAST Open Fracture Guidelines. Data was collected retrospectively for cycle one (January – December 2018) then prospectively for cycle two (November 2019 – March 2020). Between cycles, results from cycle one was used to facilitate a business case for the creation of a second scheduled weekly Orthoplastics list in our hospital.

Results

61 injuries met inclusion criteria in cycle one and 23 in cycle two. In cycle one, 28% of cases missed the 72-hour soft tissue coverage target, 11% missed the 7-day target. Only 10% of cases had both Orthopaedics and Plastics consultants involved at initial debridement. Following the invention of an additional weekly Orthoplastics list, the percentage of patients missing the 7-day target for soft tissue coverage halved to 5% and the percentage of cases with both Orthopaedics and Plastics consultants involved at initial debridement more than doubled to 26%.

Conclusions

We advocate multiple weekly Orthoplastics lists to ensure prompt consultant-led management and minimise delays for patients with open fractures. We have demonstrated that audit of current practice is a simple and effective tool to facilitate improvement in guideline compliance.

[Reconstruction of metadiaphyseal bone defects of the femur with cortical strut allografts in periprosthetic bone loss]

OBJECTIVE

Biological augmentation and stabilization of high-grade bone defects with structural allografts from donor femur halfs.

INDICATIONS

Severe bone defects with aseptic loosening of hip prosthesis, periprosthetic femoral fracture or non-union, possibly even in cases of a healed infection.

CONTRAINDICATIONS

Local or systemic infection.

SURGICAL TECHNIQUE

The two modeled strut allografts are temporary fixed epiperiostal anterolateral and -medial with wire cerclages, while protecting the vascular supplying linea aspera of the femur. With the thus stabilized femur, the leg can be placed in the four-position in order to prepare the medullary canal of the revision prosthesis. Finally, the uncemented revision prosthesis is hammered in under successive tightening of the wire cerclages. With this "cracking technique", stem is stabilized and the grafts have repositioning, augmentative, and supportive function.

POSTOPERATIVE MANAGEMENT

Partial weight-bearing postoperatively for 12 weeks. X-ray control during surgery, 10 days postoperatively, after 6 and 12 weeks and every 1-2 years.

RESULTS

In four different studies, 123 patients were stabilized from December 1991 to June 2011 due to an extensive periprosthetic femoral bone defect and/or periprosthetic fracture, refracture, or non-union with strut allografts. After an average follow-up of 3.8 years (range 0.3-11 years), the average Harris Hip Score was 80.8 (range 44-100). During this time, there was 1 refracture, 103 stable stems, 20 fibrous stable stems, 9 patients with low graft resorption, and 122 patients with radiographic healing of the strut allografts based on classification according to Emerson et al. (Clin Orthop Relat Res 285:35-44, 1992).

Natural history of a visceral leishmaniasis outbreak in highland Ethiopia

In May 2005, visceral leishmaniasis (VL) was recognized for the first time in Libo Kemken, Ethiopia, a highland region where only few cases had been reported before. We analyzed records of VL patients treated from May 25, 2005 to December 13, 2007 by the only VL treatment center in the area, maintained by Médecins Sans Frontières-Ethiopia, Operational Center Barcelona-Athens. The median age was 18 years; 77.6% were male. The overall case fatality rate was 4%, but adults 45 years or older were five times as likely to die as 5-29 year olds. Other factors associated with increased mortality included HIV infection, edema, severe malnutrition, pneumonia, tuberculosis, and vomiting. The VL epidemic expanded rapidly over a several-year period, culminating in an epidemic peak in the last third of 2005, spread over two districts, and transformed into a sustained endemic situation by 2007.

Epidemiology and clinical features of patients with visceral leishmaniasis treated by an MSF clinic in Bakool region, Somalia, 2004-2006

Background

There are few reports describing the epidemiology of visceral leishmaniasis (VL) in Somalia. Over the years 2002 to 2005, a yearly average of 140 patients were reported from the Huddur centre in Bakool region, whereas in 2006, this number rose to 1002 patients. Given the limited amount of information on VL and the opportunity to compare features with the studies done in 2000 in this part of Somalia, we describe the epidemiologic and clinical features of patients who presented to the Huddur treatment centre of Bakool region, Somalia, using data routinely collected over a five-year observation period (2002–2006).

Methodology

Methods used included the analysis of routine data on VL cases treated in the Huddur treatment centre, a retrospective study of records of patients admitted between 2004 and 2006, community leaders interviews, and analysis of blood specimens taken for parasite species identification in Antwerp Institute of Tropical Medicine.

Principal Findings

A total of 1671 VL patients were admitted to the Huddur centre from January 2002 until December 2006. Nearly all patients presented spontaneously to the health centre. Since 2002, the average patient load was stable, with an average of 140 admissions per year. By the end of 2005, the number of admissions dramatically increased to reach a 7-fold increase in 2006. The genotype of L. donovani identified in 2006 was similar to the one reported in 2002. 82% of total patients treated for VL originated from two districts of Bakool region, Huddur and Tijelow districts. Clinical recovery rate was 93.2% and case fatality rate 3.9%.

Conclusions

After four years of low but constant VL case findings, a major increase in VL was observed over a 16-month period in the Huddur VL centre. The profile of the patients was pediatric and mortality relatively low. Decentralized treatment centers, targeted active screening, and community sensitization will help decrease morbidity and mortality from VL in this endemic area. The true magnitude of VL in Somalia remains unknown. Further documentation to better understand transmission dynamics and thus define appropriate control measures will depend on the stability of the context and safe access to the Somali population.

Our paper describes the epidemiological features of visceral leishmaniasis in the Bakool region, South Central Somalia, over the years 2004 to 2006. Since 2000, Médecins Sans Frontières has been providing care for patients suffering from visceral leishmaniasis in Huddur, located in a region endemic for visceral leishmaniasis. By the end of 2005, we witnessed a dramatic increase in the number of patients admitted to the Huddur centre with visceral leishmaniasis. In our paper, we provide a description of the profile of patients admitted, thus giving an insight into the epidemiology of visceral leishmaniasis in a part of the world where relatively little has been documented and where the true magnitude of this neglected disease remains unknown.

Kala-azar outbreak in Libo Kemkem, Ethiopia: epidemiologic and parasitologic assessment

In May 2005, visceral leishmaniasis (VL) was recognized for the first time in Libo Kemkem, Ethiopia. In October 2005, a rapid assessment was conducted using data from 492 patients with VL treated in the district health center and a household survey of 584 residents of four villages. One subdistrict accounted for 71% of early cases, but the incidence and number of affected subdistricts increased progressively throughout 2004-2005. In household-based data, we identified 9 treated VL cases, 12 current untreated cases, and 19 deaths attributable to VL (cumulative incidence, 7%). Thirty percent of participants were leishmanin skin test positive (men, 34%; women, 26%; P = 0.06). VL was more common in men than women (9.7% versus 4.5%, P < 0.05), possibly reflecting male outdoor sleeping habits. Molecular typing in splenic aspirates showed L. infantum (six) and L. donovani (one). Local transmission resulted from multiple introductions, is now well established, and will be difficult to eradicate.

Safety and efficacy of trastuzumab every 3 weeks combined with cytotoxic chemotherapy in patients with HER2-positive recurrent breast cancer: findings from a case series

BACKGROUND

Trastuzumab has been repeatedly shown to result in significant clinical benefits and was subsequently accepted as the treatment of choice for HER2-positive advanced breast cancer - particularly as first-line treatment in combination with taxanes and as monotherapy in the second-line or third-line setting. Trastuzumab is currently licensed as a weekly treatment, although a 3-weekly schedule could be used conveniently in combination with other cytotoxic agents that are administered on a 3-weekly basis in metastatic breast cancer.

PATIENTS AND METHODS

We determined the safety of i.v. trastuzumab (8 mg/kg followed by 6 mg/kg) every 3 weeks in combination with chemotherapeutic agents administered in 3-weekly courses (docetaxel, vinorelbine and capecitabine) in 31 patients with HER2-positive recurrent locoregional and/or metastatic breast cancer.

RESULTS

3-weekly trastuzumab appeared to be as well tolerated as the standard once-weekly schedule. All myelosuppressive adverse events and the majority of non-hematological adverse events were typical and characteristic of the individual concomitant cytotoxic agents. Transient trastuzumab-related infusion reactions occurred in 5 patients and 1 patient developed cardiac dysfunction, which recovered after discontinuation of trastuzumab. Efficacy appeared favourable: 18 clinical responses (3 complete and 15 partial) and 8 disease stabilizations gave an overall response rate of 58% (70% in the 20 patients receiving first-line therapy). Median progression-free and overall survival times were 9.9 months (95% CI: 6.3-13.5) and 23.1 months (95% CI: 19.2-27.0), respectively.

CONCLUSIONS

These findings will likely encourage further evaluation of this more convenient 3-weekly trastuzumab regimen in patients with HER2-positive metastatic breast cancer.

Developmental transitions in the myosin patterns of two fast muscles

Transitions in myosin patterns were examined in situ by immunofluorescence in two fast muscles of the developing chicken, the pectoralis and the posterior latissimus dorsi. Myosin isoforms were localized using stage-specific monoclonal antibodies against the heavy chain of pectoralis myosin. Two antibodies (12C5 and 10H10) recognize adult and late embryonic myosin. They reacted weakly with both the pectoralis and posterior latissimus dorsi at 10 days in ovo, but intensely at 18 days in ovo. Both muscles were completely unreactive with an adult-specific antibody (5C3), indicating that the staining with 12C5 and 10H10 at 18 days in ovo reflects embryonic myosin. Thus two different embryonic isoforms are expressed sequentially in each muscle. Both 12C5 and 10H10 reacted weakly again with these muscles after hatching. The reappearance of a strong positive response to both antibodies, at 28 days in the pectoralis and after 60 days in the posterior latissimus dorsi, correlated well with the first appearance of a response to the adult-specific antibody, 5C3, signalling the beginning of the adult pattern. Both muscles reacted strongly with an antibody (5B4) specific for 'neonatal' myosin between 18 days in ovo and 60 days after hatching. In the pectoralis, embryonic was replaced by neonatal myosin in most fibres by 14 days after hatching; by 28 days, both adult and neonatal myosin were expressed in most fibres; and in the adult, neonatal myosin was replaced entirely by the adult isoform. In contrast, many fibres in the posterior latissimus dorsi still expressed both embryonic and neonatal myosins up to at least 60 days post-hatch, and the remaining fibres expressed the neonatal isoform; the neonatal isoform was present in some fibres even in the adult posterior latissimus dorsi. We have therefore demonstrated in situ four different heavy chain isoforms in two different fast muscles. 'Early embryonic', 'late embryonic', 'neonatal' and eventually 'adult' isoforms are expressed in each muscle and more than one isoform often coexists in the same fibre.