Emerging Healthcare Problem Research Articles

THE DIRECT COSTS OF HIP FRACTURE CARE IN SOUTH AFRICA: A PUBLIC HEALTHCARE SYSTEM PERSPECTIVE

Fragility fractures are an emerging healthcare problem in Sub-Saharan Africa and hip fractures (HFs) are associated with high levels of morbidity, prolonged hospital stays, increased healthcare resources utilization, and mortality. The worldwide average healthcare cost in the first-year post HF was US$43,669 per patient in a 2017 systematic review, however there are no studies quantifying fracture-associated costs within SSA. We estimated direct healthcare costs of HF management in the South African public healthcare system.We conducted a prospective ingredients-based costing study in 200 consecutive consenting HF patients to estimate costs per patient across five regional public sector hospitals in KwaZulu-Natal (KZN). Resource use including staff time, consumables, laboratory investigations, radiographs, operating theatre time, surgical implants, medicines, and inpatient days were collected from presentation to discharge. Counts of resources used were multiplied by relevant unit costs, estimated from KZN Department of Health hospital fees manual 2019/20, in local currency (South African Rand, ZAR). Generalised linear models were used to estimate total covariate adjusted costs and cost predictors.The mean unadjusted cost for HF management was ZAR114,179 (95% CI; ZAR105,468–125,335). The major cost driver was orthopaedics/surgical ward costs ZAR 106.68, contributing to 85% of total cost. The covariate adjusted cost for HF management was ZAR114,696 (95% CI; ZAR111,745–117,931). After covariate adjustment, total costs were higher in patients operated under general anaesthesia compared to surgery under spinal anaesthesia and no surgery.Direct healthcare costs following a HF are substantial: 58% of the gross domestic per capita (US$12,096 in 2020), and six-times greater than per capita spending on health (US$1,187 in 2019) in SA. As the population ages, this significant economic burden to the health system will increase. Further research is required to evaluate direct non-medical, and the indirect costs incurred post HF.

Maxillofacial trauma among Indians.

Orofacial injuries constitute the medico-legal cases reported, especially, in cases associated with road traffic accidents, assaults, and violence making it an emerging healthcare problem. Therefore, it is of interest to document data on the maxillofacial trauma and fractures among Indians. 150 subjects within the age of 15 to 60 years with maxillofacial fractures, detailed medical history including demographics, radiographs, medical history, associated injuries, and etiology of fractures were used for this study. Sites for both maxillary and mandibular fractures were noted. The type of intubation (medical insertion procedure) used and post-operative complications were also recorded. Lefort I, II, and III fractures were seen in 4%, 12%, 6% subjects respectively, whereas, ZMC fracture was seen in 66% study subjects. Mandibular fractures were most commonly seen in the para-symphysis region with 30% subjects followed by condylar region with 28.66% subjects. Data shows that maxillofacial trauma has a high incidence in India with RTA (road traffic accidents being the most common reason for the trauma seen in young males with significant concomitant injuries. Most common fracture is seen in mandible region. However, they can be managed well with very few postoperative complications.

Hip fractures: mortality and correlation with preoperative comorbidities in Indian elderly population

<p class="abstract"><strong>Background:</strong> Hip fractures are an emerging health care problem due to increase in the elderly population all over the world and the associated complications, morbidity and mortality. The objective of this study is to find out the mortality rates in Indian elderly population with hip fractures and to establish an association between various related complications pre and post operatively for a better risk stratification.</p><p class="abstract"><strong>Methods: </strong>A prospective observational cohort study, was carried out at a high-volume orthopaedic centre from 2009 to 2018. And all patients managed for hip fractures were followed up till death or 05 years.</p><p class="abstract"><strong>Results: </strong>The age adjusted first-year mortality was found to be 33% with statistically significant increase in the mortality in individuals with three or more pre-op comorbidities. The significantly associated co-morbidities were chronic renal failure (Hazard ratio 2.32 with CI 1.65- 3.24) and diabetes mellitus (Hazard ratio 1.66 with CI 1.25 – 2.21). There has been a significant dip in the cumulative survival rates of these individuals irrespective of age, sex, preop anaemia.</p><p class="abstract"><strong>Conclusions: </strong>A knowledge about the comorbidities/ risk factors and the extent to which they influence the long-term survival in the geriatric hip fracture patients can help treating physician to effectively prioritise and plan management in coordination with allied specialities. </p>

Epidemiology of Sepsis Syndrome among Intensive Care Unit Patients at a Tertiary University Hospital in Palestine in 2019.

BackgroundSepsis syndrome is an emerging healthcare problem, especially in critically ill patients, regardless whether it's community- or hospital-acquired sepsis. This study evaluates the characteristics of these patients, in addition to the type, source, and outcome of sepsis and septic shock, in a university tertiary hospital in Palestine. It also studies the most common organisms encountered in these patients.Materials and methodsThis is retrospective observational chart review study of all adult admissions to the intensive care unit over a period of 2 years. The presence of sepsis and septic shock was assessed and documented based on the Third International Consensus Definitions (Sepsis-3). Data regarding demographics, severity, comorbidities, source of infection, microbiology, length of stay, and outcomes (dead/alive at discharge from ICU) were recorded.ResultsA total number of 174 patients were included. The mean age was 57.4 years, with cardiovascular diseases and diabetes being the leading comorbidities encountered in them. Respiratory infections were the most common site of sepsis, found in around 71% of patients, followed by urinary tract infections. More than 70% of cases were due to hospital-acquired infections (HAIs). Acinetobacter species were the most common gram-negative organisms encountered, while Enterococcus was the most common gram-positive organisms. Around 54% of patients had multidrug-resistant organisms. The average length of stay in the ICU was 8 days. The average mortality rate was 39.7%, which is higher among septic shock patients.ConclusionBoth sepsis and septic shock carry high morbidity and mortality rates, and they are very frequent among critically ill patients. Special care and developing management bundles are crucial in controlling and preventing this threat.How to cite this articleRabee HA, Tanbour R, Nazzal Z, Hamshari Y, Habash Y, Anaya A, et al. Epidemiology of Sepsis Syndrome among Intensive Care Unit Patients at a Tertiary University Hospital in Palestine in 2019. Indian J Crit Care Med 2020;24(7):551–556.

Community respite service utilisation and dementia care: a review of literature

Objective: To explore the detrimental effects of caregiver burden, in relation to caregivers of people with dementia, and highlight caregiver burden as an emerging health care problem. The purpose of the literature review is to inform health care professionals of the barriers to utilizing community respite services by caregivers and discuss the significance of respite services to caregivers of people with dementia. Background: Dementia is one of the leading contributors to burden of disease and disability. Increasing numbers of spouse and family caregivers play crucial roles in providing support for people with dementia enabling them to continue living in the community. Caregiver burden occurs in individuals when the demands of caregiving exceeds their resources. Community respite services are valuable resources which provide individuals a break from their caregiving role. Study design and methods: The literature review will draw attention to caregivers of people living with dementia in the community and their utilization of community respite services. The target audience are health care professionals in multidisciplinary community teams composed of clinicians, educators, managers, administrators, and researchers. Seven online databases were accessed to search the following terms of caregiver burden, dementia care and community respite along with specific inclusion criteria. As a result, 26 scholarly articles were reviewed for the purpose of this literature review. Results: There are several community respite services, which help minimize the incidence of caregiver burden, available to caregivers of people with dementia but there are many barriers which affect utilization of these services. Some of these barriers include accessibility of information on respite services, flexibility and affordability of respite services, and the caregiver’s inability to recognize their need for respite services. Discussion: Health care professionals could assist caregivers to better utilize community respite services by performing through assessments on both people with dementia and their caregivers. As a result of these assessments, potential barriers to community respite service utilization could be identified. Implications for research: Further research is required to investigate the specific types of respite service caregivers need and which respite services have been most successful for caregivers. This knowledge can assist HCPs in improving utilization rates of respite services and inform health systems on where to focus the funding of their community resources for PWD and their caregivers. Conclusion: Community respite services are essential to minimizing the incidence of caregiver burden. Health care professionals should recognize these barriers to respite service use and implement strategies to increase service utilization. What is already known about the topic Dementia is an emerging health care problem leading to caregiver burden amongst caregivers. Community respite services help minimize the occurrence of caregiver burden. What this paper adds Contributes to the existing knowledge of caregiver burden amongst Australian health care professionals. Identifies several barriers to caregiver respite service utilization. Emphasizes the significance of respite services to caregivers of people with dementia.

PDG17 HOSPITAL COSTS ASSOCIATED WITH THE IMPLEMENTATION OF THE FALSIFIED MEDICINES DIRECTIVE IN HUNGARY

Medicine counterfeiting and its impact on patient safety is an emerging healthcare problem with an estimated annual prevalence of 0,005% (1,5 million packs) in the European legal drug supply chain. The aim of the Falsified Medicines Directive 2011/62/EU (FMD) is to prevent the entry of illegitimate medicines into the legal supply chain. There is, however, a relative lack of in-depth assessments of cost implications for hospital pharmacies. This study aims to evaluate the financial burden of FMD on Hungarian hospitals. Based on literature review and interviews with hospital pharmacy experts, a 37-question data collection form was developed to evaluate the implementation process before February 2019 and for the following stabilization period. Institutional data, infrastructural and IT developments and procedures related to authentication (verification and decommissioning) were evaluated in 3 large hospitals (900-1500 beds). Data collection started from February 2019. Authentication was performed upon shipment receipt. The average number of medication packs processed by the pharmacies was approximately 50 000 packs/month, of which on average 9 864 packs (ranging from 3 930 to 15 442) were FMD-compliant. That ratio is expected to increase over time. As human resource requirement, the added workload required 1 FTE pharmacy technician, with an estimated 7 719,23 € annual cost (ranging from 4138,77 € to 12 640,35 €). Initial one-off infrastructure and IT development costs were 2526,73 € (ranging from 77,99 € to 1 434,93 €). Our results illustrate that FMD may have a significant financial impact on hospital pharmacies. The findings of this study might offer a better understanding of influencing factors of FMD implementation in hospitals contributing to an optimized cost estimation methodology.

Surveillance cultures for detection of rectal and lower respiratory tract carriage of colistin-resistant Gram-negative bacilli in intensive care unit patients: comparison of direct plating and pre-enrichment step.

Purpose. Increasing consumption of colistin as treatment for infections with multidrug-resistant (MDR) Gram-negative bacilli (GNB) has been accompanied by increasingly frequent reports of colistin-resistant (ColR) MDR GNB. Higher selective pressure creates a favourable environment that can facilitate the spread of ColR isolates. Monitoring of asymptomatic ColR GNB carriage can give us a better understanding of this emerging healthcare problem, particularly in wards with higher polymyxin selective pressure and prevalence of carbapenem-resistant GNB. Our aim was to assess the ColR GNB colonization rate in intensive care unit (ICU) patients and evaluate the performance of two surveillance protocols using a selective medium.Methodology. A prospective study included 739 surveillance samples (rectal swabs and tracheal aspirates) from 330 patients that were screened for ColR GNB carriage using SuperPolymyxin medium. Two approaches were used: direct sample plating and overnight pre-enrichment of samples followed by plating. Colistin resistance was confirmed with broth microdilution. ColR isolates were molecularly screened for plasmid-mediated mcr genes.Results. A total of 44/739 samples (45 ColR GNB isolates) were positive for ColR GNB, which included 31/330 (9.4 %) colonized patients; mcr genes were not detected. The direct plating method only identified 17/45 (37.8 %) isolates correctly, whereas the pre-enrichment protocol identified all 45 ColR GNB.Conclusion. The colonization rate among our ICU patients was 9.4 %. Based on our findings, the pre-enrichment step is necessary for the determination of ColR GNB carriage - even though the time to result takes an additional day, fewer than half of ColR GNB carriers were detected using the direct plating protocol.

Epidemiology of Clostridium difficile infection in hospitalized adults and the first isolation of C. difficile PCR ribotype 027 in central China

BackgroundClostridium difficile infection (CDI) is an emerging healthcare problem in the world. The purpose of this study was to perform a systematic epidemiological research of CDI in Tongji hospital, the central of China.MethodsStool samples from hospitalized adults suspected of CDI were enrolled. The diagnosis of CDI were based on the combination of clinical symptoms and laboratory results. Clinical features of CDI and non-CDI patients were compared by appropriate statistical tests to determine the risk factors of CDI. Multilocus sequence typing (MLST) was employed for molecular epidemiological analysis. Susceptibility testing and relevant antimicrobial agent resistance genes were performed as well.ResultsFrom June 2016 to September 2017, 839 hospitalized adults were enrolled. Among them, 107 (12.8%, 107/839) patients were C. difficile culture positive, and 73 (8.7%, 73/839) were infected with toxigenic C. difficile (TCD), with tcdA + tcdB+ strains accounting for 90.4% (66/73) and tcdA-tcdB+ for 9.6% (7/73). Meanwhile, two TCD strains were binary toxin positive and one of them was finally identified as CD027. Severe symptoms were observed in these two cases. Multivariate analysis indicated antibiotic exposure (p = 0.001, OR = 5.035) and kidney disease (p = 0.015, OR = 8.329) significantly increased the risk of CDI. Phylogenetic tree analysis demonstrated 21 different STs, including one new ST (ST467); and the most dominant type was ST54 (35.6%, 26/73). Multidrug-resistant (MDR) TCD were 53.4% (39/73); resistance to ciprofloxacin, erythromycin, and clindamycin were > 50%. Other antibiotics showed relative efficiency and all strains were susceptible to metronidazole and vancomycin. All moxifloxacin-resistant isolates carried a mutation in GyrA (Thr82 → Ile), with one both having mutation in GyrB (Ser366 → Ala).ConclusionsKnowledge of epidemiological information for CDI is limited in China. Our finding indicated tcdA + tcdB+ C. difficile strains were the dominant for CDI in our hospital. Significant risk factors for CDI in our setting appeared to be antibiotic exposure and kidney disease. Metronidazole and vancomycin were still effective for CDI. Although no outbreak was observed, the first isolation of CD027 in center China implied the potential spread of this hypervirulent clone. Further studies are needed to enhance our understanding of the epidemiology of CDI in China.

The Wnt Signalling Pathways: A Short Review and Specific Roles in Bone Biochemistry

AbstractAs musculoskeletal diseases become an emerging healthcare problem worldwide, profound and comprehensive research has been focused on the biochemistry of bone metabolism in the past decades. Wnt signalling, one of the novel described pathways influencing bone metabolism from the early stages of tissue development, has been recently in the centre of attention. Several Wnt ligands are implied in bone forming pathways via canonical (β-catenin dependent) and non-canonical (β-catenin independent) signalling. Osteoporosis, a catabolic bone disease, has its pathologic background related, inter alia, to alterations in the Wnt signalling, thus key modulators of these pathways became one of the most promising targets in the treatment of osteoporosis. Antibodies inhibiting the activity of endogenous Wnt pathway inhibitors (sclerostin, dickkopf) are recently under clinical trials. The current article offers a brief review of the Wnt signalling pathways, its implication in bone metabolism and fate, and the therapeutic possibilities of osteoporosis through Wnt signalling.

Methamphetamine Consumption during Pregnancy – Effects on Child Health

Methamphetamine abuse during pregnancy represents an emerging health care problem. The consequences are not only of relevance to the pregnant women, but also their unborn child. It is associated with an increased risk of preeclampsia and hypertension, fetal demise, preterm delivery, and intrauterine growth restriction. The deleterious effects of prenatal methamphetamine exposure on the developing fetal brain may lead to long-term neuro-developmental and behavioral problems.Given the current evidence, abuse of methamphetamine during pregnancy must be of utmost concern to health care professionals and to policy-makers. As it has been described for neonatal abstinence syndrome, a multi-professional team is required to improve care of affected women and families. A multi-disciplinary approach is needed, including good prenatal care of pregnant women, perinatal care by specialized obstetricians and neonatologists, and psychiatric treatment by an addiction specialist. Furthermore, families should be integrated into appropriate social support networks.For the development of a structured support program for pregnant women with methamphetamine consumption, methamphetamine use disorder should be considered as a disease that requires medical treatment as well as psychological and social support. The pregnancy should be considered as a window of opportunity to provide the required help.

A Comparison of Current Guidelines of Five International Societies on Clostridium difficile Infection Management.

Clostridium difficile infection (CDI) is increasingly recognized as an emerging healthcare problem of elevated importance. Prevention and treatment strategies are constantly evolving along with the apperance of new scientific evidence and novel treatment methods, which is well-reflected in the differences among consecutive international guidelines. In this article, we summarize and compare current guidelines of five international medical societies on CDI management, and discuss some of the controversial and currently unresolved aspects which should be addressed by future research.Electronic supplementary materialThe online version of this article (doi:10.1007/s40121-016-0122-1) contains supplementary material, which is available to authorized users.

Nutritional Care of the Obese Adult Burn Patient

Obesity is an emerging healthcare problem and affects an increasing number of burn patients worldwide. An email survey questionnaire was constructed and distributed among the 16 U.K. burn services providing adult inpatient facilities to investigate nutritional practices in obese thermally injured patients. Responses received from all dieticians invited to participate in the study were analyzed, and a relevant literature review of key aspects of nutritional care is presented. The majority of services believe that obese patients warrant a different nutritional approach with specific emphasis to avoid overfeeding. The most common algebraic formulae used to calculate calorific requirements include the Schofield, Henry, and modified Penn State equations. Indirect calorimetry despite being considered the "criterion standard" tool to calculate energy requirements is not currently used by any of the U.K. burn services. Gastric/enteral nutrition is initiated within 24 hours of admission in the services surveyed, and a variety of different practices were noted in terms of fasting protocols before procedures requiring general anesthesia/sedation. Hypocaloric regimens for obese patients are not supported by the majority of U.K. facilities, given the limited evidence base supporting their use. The results of this survey outline the wide diversity of dietetic practices adopted in the care of obese burn patients and reveal the need for further study to determine optimal nutritional strategies.

Appendicectomy and clostridium difficile infection: is there a link?

Clostridium difficile infection (CDI) is a gradually emerging healthcare problem in the western world, occurring predominantly from the de-arrangement of the gut microbiota and the widespread use of antibiotics. Recently, it has been proposed that the presence or absence of the appendix could be a factor influencing the occurrence and/or the severity of CDI. We performed a review of the literature, aiming to identify and interpret in an accumulative way the results of the published clinical studies which addressed the issue of a possible association between prior appendicectomy and the features of CDI. A total of five suitable studies were retrieved, which were all conducted retrospectively. Although the results were conflicting regarding the impact of prior appendicectomy in the occurrence and relapse of CDI, it appears that the presence or absence of the appendix is not associated with the clinical severity of CDI. Based on the current evidence and considering the effects of the widespread use of antibiotics in the clinical practice, it appears that an in situ appendix does not have a definitive impact on the development and severity of CDI. Further observational studies are warranted to clarify any potential association.

Epidemiology of Mucormycosis in India

Mucormycosis is an emerging healthcare problem in the Indian population. The epidemiology of the disease is distinct with very high incidence among uncontrolled diabetics. The patients present commonly as rhino-orbito-cerebral mucormycosis, which is easy to diagnose. But, the mortality rate remains high (nearly 50 %), as the patients attend the healthcare facility late in the course of the disease after extensive spread of infection. Isolated renal mucormycosis in young apparently healthy individuals is a new form of the disease. The spectrum of etiological agents causing mucormycosis is also unique as Apophysomyces elegans is the second most common pathogen after Rhizopus oryzae. Many new agents are identified causing the disease.

Homozygosity for the Mediterranean α-thalassemic deletion (hemoglobin Barts hydrops fetalis)

Hemoglobin Barts hydrops fetalis syndrome is the most severe and generally fatal clinical phenotype of α-thalassemia. We diagnosed a fetus at 23-weeks gestation with having hydrops fetalis, by ultrasound. At 32 weeks, intrauterine death was detected. Molecular studies revealed that the fetus had the hemoglobin Barts hydrops fetalis syndrome due to homozygosity for the Mediterranean α-thalassemia deletion. This clinical phenotype is generally rare in the Eastern Mediterranean, and this is the first report of this syndrome from Iraq. Techniques for molecular characterization became available only very recently in this country, in a diagnostic setting. Thus, the detection of further cases might be expected in future.

Pain Prevalence in Singapore

The prevalence of chronic pain is well described in various parts of the world; primarily in Western societies such as Europe, America and Australia. Little is known of the prevalence of chronic pain within Asia or Southeast Asia. In view of the cultural and genetic variation in pain causation, manifestation and reporting, the findings of previous studies cannot be translated to Asian countries. Prevalence studies needed to be carried out to quantify the magnitude and impact of chronic pain within Asian countries to properly allocate precious health funds to deal with this important healthcare issue. We report the findings of the prevalence study within one Asian country: Singapore. To determine the prevalence and impact of chronic pain in adult Singaporeans. Two sets of questionnaires were designed. The first, a screening questionnaire, to identify the prevalence of chronic pain, and should there be chronic pain; the second, a detailed questionnaire was administered, to characterise the features and the impact of pain. A cross-sectional sampling of Singapore adults were achieved using a computer-based multi-step random sampling of listed telephones numbers. The questionnaires were administered via telephone by a trained interviewer with the aid of a computer-assisted telephone interview system. A total of 4141 screening and 400 detailed questionnaires were completed. The prevalence of chronic pain, defined as pain of at least 3 months' duration over the last 6 months was 8.7% (n = 359). There was a higher prevalence in females (10.9%) and with increasing age. In particular, pain prevalence increased steeply beyond the age of 65 years old. There was a significant impact on work and daily function of those with chronic pain. Though the prevalence of chronic pain was marginally lower compared other studies, the impact of pain was just as significant. In a rapidly ageing population such as Singapore, chronic pain is an important emerging healthcare problem which will likely exert increasing toll on the existing social infrastructure within the next 5 to 10 years.

Editorial Comment

During the past 140 years, the United States has experienced an increased productivity and demand for firearms. The emergence of the American gun culture seems to coincide with the production of mass produced firearms resulting from the technological breakthroughs realized as a result of the Civil War. Despite the congressional efforts to provide restrictions on federal firearms licenses with the passage of the 1994 crime bill, there still are 140,000 authorized sellers of firearms in the United States. 1 “Most of the world associates the United States with firearms, if not as the world’s leading maker of guns, then for such global cultural icons as the cowboy, the gangster, the street thug, and the heroic cop.”1 In 1962, the number of firearm-related deaths was 16,720 increasing to 38,505 deaths in 1994. 3 In 1998, firearm-related injuries were the second leading cause of death after motor vehicle-related deaths. 2 Although the firearm-related injury rates decreased between 1993 and 1998, the estimated average number of firearm-related injuries was 115,000 with 30% resulting in death. Of these injuries, more than 70% of unintentional injuries and more than 45% of intentional nonfatal injuries were gunshot wounds to the extremities. 1,2 Given the enormity of this public health problem, we are forced to examine the etiology, to identify the available economic resources, to form an effective political response, to provide public access to education, and to reevaluate the medical science of our trauma protocols. Ostensibly, this symposium will not be able to address the myriad issues associated with this emerging healthcare problem. Alternatively, we hope to provide an overview of the relevant ethical issues and to address the thinking and science of the current medical treatment of firearm-related musculoskeletal injuries. In this symposium, Cornwell urges an emphasis on the evidence-based improvement of trauma systems nationwide with special attention directed toward the appropriate principles of triage, emergent transport, and the critical first-hour of intervention. A balanced discussion of the ethical issues relevant to gun control in the United States is provided by Boylan’s essay highlighting the contrasting and passionately contested world views of the gun control debate through thought-provoking appraisal of both sides of the discussion. Shepard et al evaluate the reliability of the Association Osteosynthesis/Orthopaedic Trauma Association classification system for the evaluation of the femur fractures caused by gunshots. Their retrospective radiographic review of femur fractures tests the limits of interobserver and intraobserver reliability of this classification system. Additionally, Long et al propose a new classification system of gunshot femur fractures based on a retrospective study of more than 100 femur fractures. Gugala and Lindsey introduce a new classification of gunshot injuries in civilians based on specific parameters including missile energy, vital structures involved, wound characteristics, fracture patterns, and the extent of wound contamination. The studies by Johnson and Strauss, Wilson, Holmes, Zura and Bosse, Kitchel, Waters and Sie, Smith et al, and Simpson and Grant are underscored by the definitive review of the history and evolution of ballistics developed by Bartlett during the past several years. Bartlett’s contribution to increasing our understanding of ballistics allows his review of the literature to serve as a primary source and future reference for our evolving treatment protocols for patients with gunshot injuries. We hope that this symposium will serve as an overview of the emerging public healthcare crisis resulting from firearm-related musculoskeletal injuries. Although new technologies and evidence-based clinical outcomes have changed our approach to the treatment of patients with gunshot-induced injuries, the trauma community still is faced with the consequences of advancing firearm technologies and the indirect marketing influences of popular culture. Finally, the guest editors are appreciative of the guidance and assistance of the outgoing Editor-in-Chief of Clinical Orthopaedics and Related Research, Dr. Carl T. Brighton, for encouraging the development and completion of this project for the benefit of the orthopaedic community and the numerous subspecialties that support our trauma efforts.

Hydrops Fetalis Caused by α-Thalassemia: An Emerging Health Care Problem

Hydrops Fetalis Caused by α-Thalassemia: An Emerging Health Care Problem