We investigated the incidence of complications following childhood clavicle fractures and the necessity for follow-up in fracture clinic after the first orthopaedic consultation. We found that review in fracture clinic has no impact upon the outcome of clavicle fractures and complications such as non-union, mal-union or neurovascular problems are exceptionally rare. We concluded that there is no need for follow-up of children with isolated, uncomplicated clavicle fractures. These patients should be discharged after their first assessment in fracture clinic.
ObjectivesRoutine HIV testing in nonspecialist settings has been shown to be acceptable to patients and staff in pilot studies. The question of how to embed routine HIV testing, and make it sustainable, remains to be answered. MethodsWe established a service of routine HIV testing in an emergency department (ED) in London, delivered by ED staff as part of routine clinical care. All patients aged 16 to 65 years were offered an HIV test (latterly the upper age limit was removed). Meetings were held weekly and two outcome measures examined: test offer rate (coverage) and test uptake. Sustainability methodology (process mapping; plan-do-study-act (PDSA) cycles) was applied to maximize these outcome measures. ResultsOver 30 months, 44 582 eligible patients attended the ED. The mean proportion offered an HIV test was 14%, varying from 6% to 54% per month over the testing period. The mean proportion accepting a test was 63% (range 33-100%). A total of 4327 HIV tests have been performed. Thirteen patients have been diagnosed with HIV infection (0.30%). PDSA cycles having the most positive and sustained effects on the outcome measures include the expansion to offer blood-based HIV tests in addition to the original oral fluid tests, and the engagement of ED nursing staff in the programme. ConclusionsHIV testing can be delivered in the ED, but constant innovation and attention have been required to maintain it over 30 months. Patient uptake remains high, suggesting acceptability, but time will be required before true embedding in routine clinical practice is achieved.Keywords: HIV testing, Emergency Department, non-specialist settings, sustainability methodology, feasibility, acceptability Accepted 12 June 2013 IntroductionThe UK HIV epidemic is characterized by a high proportion of late-stage diagnoses, and of a persistently high proportion of undiagnosed infections [1]. Guidance from the National Institute for Health and Clinical Excellence follows that from the British Association for Sexual Health and HIV, and the British HIV Association, in calling for more widespread testing, including routine HIV testing in general medical settings in areas where HIV prevalence exceeds 0.2% [2][3][4][5].The HIV Testing in Non-traditional Settings (HINTS) study was one of several Department of Health-funded studies commissioned to evaluate the acceptability, feasibility and effectiveness of implementing these guidelines. Routine HIV testing services were established in four contexts, all in high-prevalence areas in London, UK: an emergency department (ED), an acute assessment unit, an out-patient department, and a primary care centre. Over SHORT COMMUNICATION 6 4 months, 6194 patients were offered HIV tests (51% of all age-eligible patients). The uptake was 67%, with 4105 tests performed. Eight individuals (0.19%) were newly diagnosed with HIV infection and all were transferred to care. Of 1003 questionnaire respondents, the offer of an HIV test was acceptable to 92%. In all settings, additional specialist staff and/or infrastructura...
About 3ie The International Initiative for Impact Evaluation (3ie) promotes evidence-informed, equitable, inclusive and sustainable development. We support the generation and effective use of high-quality evidence to inform decision-making and improve the lives of people living in poverty in low-and middle-income countries. We provide guidance and support to produce, synthesise and quality assure evidence of what works, for whom, how, why and at what cost. 3ie impact evaluations 3ie-supported impact evaluations assess the difference a development intervention has made to social and economic outcomes. 3ie is committed to funding rigorous evaluations that include a theory-based design and that use the most appropriate mix of methods to capture outcomes and are useful in complex development contexts. About this report 3ie accepted the final version of the report, Rebuilding the social compact: urban service delivery and property taxes in Pakistan, as partial fulfilment of requirements under grant DPW1.1005 awarded through Development Priorities Window 1. The report is technically sound and 3ie is making it available to the public in this final report version as it was received. No further work has been done. The 3ie technical quality assurance team for this report comprises Francis Rathinam, Neeta Goel, Kanika Jha Kingra and Deeksha Ahuja, an anonymous external impact evaluation design expert reviewer and an anonymous external sector expert reviewer, with overall technical supervision by Marie Gaarder. The 3ie editorial production team for this report comprises Anushruti Ganguly and Akarsh Gupta.
Pulmonary vascular disease (PVD) is a significant global health problem and accounts for a substantial portion of cardiovascular disease in the developing world. Although there have been considerable advances in therapeutics for pulmonary arterial hypertension, over 97% of the disease burden lies within the developing world where there is limited access to health care and pharmaceuticals. The causes of pulmonary arterial hypertension differ between industrialized and developing nations. Infectious diseases-including schistosomiasis human immunodeficiency virus, and rheumatic fever-are common causes of PVD, as are hemoglobinopathies, and untreated congenital heart disease. High altitude and exposure to household air pollutants also contribute to a significant portion of PVD cases. Although diagnosis of pulmonary arterial hypertension requires the use of imaging and invasive hemodynamics, access to equipment may be limited. PVD therapies may be prohibitively expensive and limited to a select few. Prevention is therefore important in limiting the global PVD burden.
Annals welcomes letters to the editor, including observations, opinions, corrections, very brief reports, and comments on published articles. Letters to the editor should not exceed 500 words and 5 references. They should be submitted using Annals' Web-based peer review system, Editorial Manager TM (http://www.editorialmanager.com/annemergmed). Annals no longer accepts submissions by mail.Letters should not contain abbreviations. Financial association or other possible conflicts of interest should always be disclosed, and their presence or absence will be published with the correspondence. Letters discussing an Annals article must be received within 8 weeks of the article's publication.Published letters may be edited and shortened. Authors of articles for which comments are received will be given the opportunity to reply. If those authors wish to respond, their reply will not be shared with the author of the letter before publication.Neither Annals of Emergency Medicine nor the Publisher accepts responsibility for statements made by contributors.
INTRODUCTION The British Orthopaedic Association published guidelines on the care of fragility fracture patients in 2003. A section of these guidelines relates to the secondary prevention of osteoporotic fractures. The objective of this audit was to compare practice in our fracture clinic to these guidelines, and take steps to improve our practice if required.PATIENTS AND METHODS We retrospectively audited the treatment of all 462 new patients seen in January and February 2004. Using case note analysis, 38 patients who had sustained probable fragility fractures were selected. Six months' post-injury, a telephone questionnaire was administered to confirm the nature of the injury and to find out whether the patient had been assessed, investigated or treated for osteoporosis. A second similar audit was conducted a year later after steps had been taken to improve awareness amongst the orthopaedic staff and prompt referral.RESULTS During the first audit period, only 5 of 38 patients who should have been assessed and investigated for osteoporosis were either referred or offered referral. This improved to 23 out of 43 patients during the second audit period.CONCLUSIONS Improvements in referral and assessment rates of patients at risk of further fragility fractures can be achieved relatively easily by taking steps to increase awareness amongst orthopaedic surgeons, although additional strategies and perhaps the use of automated referral systems may be required to achieve referral rates nearer 100%.
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