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Background: The rate of open tibia fractures is rapidly increasing across the globe due to a recent rise in road traffic accidents, predominantly in low and low-middle income countries. These injuries are orthopaedic emergencies associated with infection rates as high as 40% despite the use of systemic antibiotics and surgical debridement. The use of local antibiotics has shown some promise in reducing the burden of infection in these injuries due to increasing local tissue availability, however no trial has yet been appropriately powered to evaluate for definitive evidence and the majority of current studies have taken place in a high-resource countries where resources and the bio-burden may be different. • Methods: This is a prospective randomized, masked, placebo-controlled superiority trial designed to evaluate the efficacy of locally administered gentamicin versus placebo in the prevention of fracture-related infection in adults (age>18 years) with primarily closeable Gustillo-Anderson class I, II, and IIIA open tibia fractures. Eight hundred and nighty patients will be randomized to receive an injection of either gentamicin (treatment group) or saline (control group) at the site of their primarily closed open fracture. The primary outcome will be the occurrence of a fracture related infection occurring during the course of the 12-month follow-up. Discussion: This study will definitively assess the effectiveness of local gentamicin for the prevention of fracture-related infections in adults with open tibia fractures in Tanzania. The results of this study have the potential to demonstrate a low-cost, widely available intervention for the reduction of infection in open tibia fractures. Trial registration: Clinicaltrials.gov identifier: NCT05157126. Registered on December 14th, 2021.

Point-of-care ultrasound (POCUS) is used to manage patients in real time. This study aimed to teach pediatric critical care team members to use POCUS for endotracheal tube (ETT) placement confirmation. A secondary aim was to assess the feasibility of a remote curriculum for this purpose.The Kern 6-step approach was used. The curriculum involved virtual didactics, asynchronous learning modules, and remote hands-on sessions using teleguidance with the Butterfly IQ+ probe, Butterfly Network, Inc, Guilford, CT. Participants learned direct and indirect methods of ETT placement confirmation and were directed to practice independently. Outcomes included attitudes and satisfaction, knowledge and skills acquisition and retention, and the use of POCUS on shift.Ten participants completed the curriculum. The average knobology and quiz scores improved by 29.3% and 20.8%, respectively. Improvement was sustained at re-evaluation. Seven of 10 participants performed independent scans. At the 3-month reassessment, most demonstrated mastery of thoracic scans. All required prompting for satisfactory tracheal scans. All felt positively toward POCUS and the remote curriculum.Pediatric critical care team members acquired and retained knowledge and skills for POCUS basics and ETT placement confirmation through a remote curriculum. Participants were satisfied with the course. Further studies are needed to reassess longer-term knowledge and skill retention and the effects on patient outcomes.

Background We aimed to examine the clinical value of serial MRSA surveillance cultures to rule out a MRSA diagnosis on subsequent cultures during a patient's surgical intensive care unit (SICU) admission. Material and Methods We performed a retrospective cohort study to evaluate patients who received a MRSA surveillance culture at admission to the SICU (n = 6,915) and collected and assessed all patient cultures for MRSA positivity during their admission. The primary objective was to evaluate the transition from a MRSA negative surveillance on admission to MRSA positive on any subsequent culture during a patient's SICU stay. Percent of MRSA positive cultures by type following MRSA negative surveillance cultures was further analyzed. Measurements and Main Results 6,303 patients received MRSA nasal surveillance cultures at admission with 21,597 clinical cultures and 7,269 MRSA surveillance cultures. Of the 6,163 patients with an initial negative, 53 patients (0.87%) transitioned to MRSA positive. Of the 139 patients with an initial positive, 30 (21.6%) had subsequent MRSA positive cultures. Individuals who had an initial MRSA surveillance positive status on admission predicted MRSA positivity rates for cultures in qualitative lower respiratory cultures (64.3% versus. 3.1%), superficial wound (60.0% versus 1.6%), deep wound (39.0% versus 0.8%), tissue culture (26.3% versus 0.6%), and body fluid (20.8% versus 0.7%) cultures when compared to MRSA negative patients on admission. Conclusion Following MRSA negative nasal surveillance cultures patients showed low likelihood of MRSA infection suggesting empiric anti-MRSA treatment is unnecessary for specific patient populations. SICU patient's MRSA status at admission should guide empiric anti-MRSA therapy.

Summary Background Prisons are recognised as high-risk environments for tuberculosis, but there has been little systematic investigation of the global and regional incidence and prevalence of tuberculosis, and its determinants, in prisons. We did a systematic review and meta-analysis to assess the incidence and prevalence of tuberculosis in incarcerated populations by geographical region. Methods In this systematic review and meta-analysis, we searched MEDLINE, Embase, Web of Knowledge, and the LILACS electronic database from Jan 1, 1980, to Nov 15, 2020, for cross-sectional and cohort studies reporting the incidence of Mycobacterium tuberculosis infection, incidence of tuberculosis, or prevalence of tuberculosis among incarcerated individuals in all geographical regions. We extracted data from individual studies, and calculated pooled estimates of incidence and prevalence through hierarchical Bayesian meta-regression modelling. We also did subgroup analyses by region. Incidence rate ratios between prisons and the general population were calculated by dividing the incidence of tuberculosis in prisons by WHO estimates of the national population-level incidence. Findings We identified 159 relevant studies; 11 investigated the incidence of M tuberculosis infection (n=16 318), 51 investigated the incidence of tuberculosis (n=1 858 323), and 106 investigated the prevalence of tuberculosis (n=6 727 513) in incarcerated populations. The overall pooled incidence of M tuberculosis infection among prisoners was 15·0 (95% credible interval [CrI] 3·8–41·6) per 100 person-years. The incidence of tuberculosis (per 100 000 person-years) among prisoners was highest in studies from the WHO African (2190 [95% CrI 810–4840] cases) and South-East Asia (1550 [240–5300] cases) regions and in South America (970 [460–1860] cases), and lowest in North America (30 [20–50] cases) and the WHO Eastern Mediterranean region (270 [50–880] cases). The prevalence of tuberculosis was greater than 1000 per 100 000 prisoners in all global regions except for North America and the Western Pacific, and highest in the WHO South-East Asia region (1810 [95% CrI 670–4000] cases per 100 000 prisoners). The incidence rate ratio between prisons and the general population was much higher in South America (26·9; 95% CrI 17·1–40·1) than in other regions, but was nevertheless higher than ten in the WHO African (12·6; 6·2–22·3), Eastern Mediterranean (15·6; 6·5–32·5), and South-East Asia (11·7; 4·1–27·1) regions. Interpretation Globally, people in prison are at high risk of contracting M tuberculosis infection and developing tuberculosis, with consistent disparities between prisons and the general population across regions. Tuberculosis control programmes should prioritise preventive interventions among incarcerated populations. Funding US National Institutes of Health.

Pedicle screws are commonly placed with lumbar/lumbosacral fusions. Triggered electromyography (tEMG), which employs the application of electrical current between the screw and a complementary anode to determine thresholds of conduction, may be utilized to confirm the safe placement of such implants. While previous research has established clinical thresholds associated with safe screw placement, there is variability in clinical practice of anode placement which could lead to unreliable measurements.To determine the variance in pedicle screw stimulation thresholds when using four unique anode locations (ipsilateral/contralateral and paraspinal/gluteal relative to tested pedicle screws).Prospective cohort study. Tertiary medical center.Twenty patients undergoing lumbar/lumbosacral fusion with pedicle screws using tEMG OUTCOME MEASURES: tEMG stimulation return values are used to assess varied anode locations and reproducibility based on anode placement.Measurements were assessed across node placement in ipsilateral/contralateral and paraspinal/gluteal locations relative to the screw being assessed. RA total of 94 lumbosacral pedicle screws from 20 patients were assessed. Repeatability was verified using two stimulations at each location for a subset of the screws with an RThe current study, a first-of-its-kind formal evaluation of anode location for pedicle screw tEMG testing, demonstrated very strong repeatability and strong correlation with different locations of anode placement. These results suggest that there is no need to change the side of the anode for testing of left versus right screws, further supporting that placing an anode electrode into gluteal muscle is sufficient and will avoid a sharp ground needle in the surgical field.

BackgroundTuberculosis notifications in Latin American prisons have more than doubled over the past two decades; however, treatment outcomes and their determinants among incarcerated individuals in this region are not well understood.MethodsNewly diagnosed drug-susceptible tuberculosis cases reported to Brazil’s Sistema de Informação de Agravos de Notificação (SINAN) between January 2015 and December 2017 were included. Multivariate logistic regression was used to assess socioeconomic and clinical factors associated with treatment success among incarcerated individuals.ResultsIncarcerated individuals (n=17,776) had greater treatment success than non-incarcerated individuals (n=160,728; 82.2% vs 75.1%, pConclusionTuberculosis treatment success among incarcerated individuals in Brazil is higher than non-incarcerated individuals, but both fall below WHO targets. Expanding the use of DOT and services for socially and medically vulnerable individuals may improve outcomes in carceral settings.

Myopericarditis has been observed among individuals receiving the BNT162b2-mRNA and mRNA-1273 COVID-19 vaccines.1,2 In this case series, we describe the initial experience with myopericarditis following COVID-19 vaccination across the largest healthcare system in Connecticut.

Since Zika virus (ZIKV) was detected in Brazil in 2015, it has spread explosively across the Americas and has been linked to increased incidence of microcephaly and Guillain-Barré syndrome (GBS). In one year, it has infected over 500,000 people (suspected and confirmed cases) in 40 countries and territories in the Americas. Along with recent epidemics of dengue (DENV) and chikungunya virus (CHIKV), which are also transmitted by Aedes aegypti and Ae. albopictus mosquitoes, the emergence of ZIKV suggests an ongoing intensification of environmental and social factors that have given rise to a new regime of arbovirus transmission. Here, we review hypotheses and preliminary evidence for the environmental and social changes that have fueled the ZIKV epidemic. Potential drivers include climate variation, land use change, poverty, and human movement. Beyond the direct impact of microcephaly and GBS, the ZIKV epidemic will likely have social ramifications for women’s health and economic consequences for tourism and beyond.