Healthcare utilization and outcomes of spinal cord injured veterans with stage 3-4 pressure injuries.

BACKGROUND: Pressure injuries (PI) are a significant source of morbidity for individuals with spinal cord injury/disease (SCI/D). They are also associated with significant healthcare resource utilization including prolonged hospitalizations. However, the long-term outcomes in terms of wound recurrence-free survival, hospital readmission rates, and all-cause mortality in this population remain largely unknown. OBJECTIVE: To examine the clinical characteristics, healthcare utilization and outcomes of SCI Veterans hospitalized at the VA North Texas Health Care System (VANTHCS) SCI inpatient unit with stage 3 and 4 PI, and compare these between those who received a myocutaneous flap surgery (flap patients (FP)) and those treated medically (non-flap patients (NFP)). METHODS: A retrospective chart review was conducted of all adult patients admitted to the VANTHCS SCI/D unit with stage 3 or 4 pelvic PI between 1/1/2013 and 12/31/2018. Healthcare utilization and outcome information was extracted for pre-specified time points. RESULTS: 78 patients met criteria (113 hospitalizations; 27 FP; 51 NFP). Average length of stay (LOS) was 122 days; FP had a significantly higher LOS than NFP (P = 0.01). Average number of consults was 24. Estimated cost per hospitalization was $175,198. Readmission rate within 30 days was 12.39%. The mortality rate within 1 year of discharge was 21.57% for NFP, as opposed to 3.70% in the FP group. Only 5.00% of NFP wounds were healed at discharged with sustained healing at 1 year, significantly less than FP wounds (55.26%, P < 0.01). CONCLUSIONS: Despite the high investment in terms of healthcare utilization, outcomes in terms of wound healing are poor. Additionally, nearly 22% of NFP died within one year of discharge. This calls into question the utility of prolonged hospitalizations for PI in the SCI/D population in terms of wound treatment efficacy, healthcare costs, and patient morbidity/mortality.

Oral Antibiotics Are Effective for the Treatment of Hand Osteomyelitis in Children.

Background: Acute osteomyelitis of the hand is common in the pediatric population. Treatment with intravenous antibiotics is expensive and is associated with catheter-site infection and thrombosis. The purpose of this study is to investigate the efficacy of managing osteomyelitis of the hand in children with oral antibiotics. Methods: A retrospective review of cases of acute osteomyelitis of the hand at a single pediatric institution over a 4.5-year period was performed. Demographic and clinical data were reviewed, and treatment courses and outcomes were analyzed. Results: In total, 21 patients with acute osteomyelitis of the hand were included in the study. Of the 21 patients, 17 were initiated on a 6-week course of oral antibiotics upon diagnosis. Thirteen were successfully treated with oral antibiotics alone, 3 required subsequent surgical debridement, and 3 required conversion to intravenous antibiotics. Of the 21 patients, 4 were treated with surgical debridement upon diagnosis due to gross purulent drainage and then initiated on a 6-week course of oral antibiotics. All patients who underwent debridement were treated successfully with postoperative oral antibiotics. Conclusions: Most cases of osteomyelitis of the hand in children can be treated with oral antibiotics, either as the primary treatment or as postoperative therapy. Surgical debridement is indicated when purulence is present at the time of initial diagnosis or if the infection progresses during treatment with oral antibiotics. The use of oral antibiotics for treating acute osteomyelitis of the hand in children may result in decreased cost and fewer catheter-associated complications.

Comparison of Fracture Location and Extent of Comminution in Isolated Scaphoid Fractures Versus Transscaphoid Fracture-Dislocations.

Background: Isolated scaphoid fractures (ISFs) are common, whereas transscaphoid fracture-dislocations (TSFDs) are not. Scaphoid fracture location and the extent of comminution are factors that affect treatment and outcome. The purpose of this study is to compare the radiographic characteristics of ISFs with TSFDs associated with greater arc injury. Methods: This study is a retrospective review of all ISFs and TSFDs that presented to our institution during a 5-year period. Fracture location (along the long axis of the scaphoid) was calculated by dividing the distance from the proximal pole to the fracture by the entire length of the scaphoid. The extent of comminution was measured in millimeters along the mid-axis of the scaphoid and divided by the entire length of the scaphoid. Results: One-hundred thirty-eight scaphoid fractures in 137 patients were identified. One-hundred twelve fractures (81%) were ISFs, and 26 (19%) were associated with a TSFD. The mean fracture location was more proximal in TSFDs than in ISFs. However, fractures occurred in the distal third of the scaphoid in 12% of ISFs compared with 0% of TSFDs. Nine percent of ISFs demonstrated comminution as compared with 12% of TSFDs. Extent of comminution was 16% and 28% for ISFs and TSFDs, respectively. Conclusion: Scaphoid fractures associated with greater arc injuries are located more proximally and are more comminuted than ISFs, and distal pole fractures rarely occur in the setting of TSFDs. The increased incidence and extent of comminution in TSFDs may be suggestive of a higher energy injury mechanism.

The Basic Science of Dupuytren Disease.

Dupuytren disease is a fibroproliferative condition affecting the hands of millions of patients worldwide. The hypothesis of pathogenesis involves genetic factors and internal factors. Recent genome-wide association studies have provided much needed evidence for the long-held belief of a strong genetic component to the pathogenesis of Dupuytren disease. Specifically, abnormal activation of the Wnt signaling pathway plays an important role. Regarding internal factors, microvascular angiopathy and ischemia have been shown to lead to activation of transforming growth factor-ß1 and proliferation of myofibroblasts.

Empiric antibiotic therapy for seawater injuries: a four-seasonal analysis.

BACKGROUND: Previous seawater studies found Vibrio species associated with morbidity, suggesting that seawater-contaminated wounds should be treated early. The purpose of this study was to identify common seawater pathogens and antibiotic sensitivities to provide empiric antibiotic therapy until patient-specific culture results are available. METHODS: Seasonal samples were collected from 25 Galveston beach locations and cultured. Colonies were identified and sensitivities were performed using MicroScan Positive and Negative Breakpoint Combo Panels. RESULTS: In the fall (28.3 degrees C), of 15 species isolated, the three most common isolates were Escherichia coli, Enterococcus faecium, and Klebsiella pneumoniae. Gram-negative isolates were sensitive to levofloxacin, lomefloxacin, and cefepime. Gram-positive isolates were sensitive to penicillin and ampicillin. In the winter (11.1 degrees C), of 14 species isolated, the three most common isolates were Enterobacter agglomerans, E. faecium, and E. coli. Gram-negative isolates were sensitive to levofloxacin, lomefloxacin, and cefepime. Most Gram-positive isolates were sensitive to vancomycin, levofloxacin, penicillin, and ampicillin. In the spring (26.6 degrees C), of 14 species isolated, the three most common isolates were E. coli, Bacillus species, and E. faecium. Gram-negative isolates were sensitive to levofloxacin, lomefloxacin, and cefepime. Most Gram-positive isolates were sensitive to penicillin, ampicillin, vancomycin, and levofloxacin. In the summer (29.7 degrees C), of 17 bacterial species isolated, the three most common isolates were Bacillus species, Enterobacter cloacae, and K. pneumoniae. Gram-negative isolates were sensitive to cefepime, lomefloxacin, and levofloxacin. Gram-positive isolates were sensitive to penicillin, ampicillin, vancomycin, levofloxacin, and chloramphenicol. CONCLUSIONS: Cultured pathogens were sensitive to penicillin, ampicillin, or levofloxacin. The authors recommend a combination of penicillin or ampicillin with levofloxacin for empiric antibiotic coverage for seawater-contaminated injuries.

Orthognathic surgery for management of Arthrogryposis Multiplex Congenita: Case report and review of the literature.

Arthrogryposis Multiplex Congenita is a condition characterized by multiple contractures of the joints. Involvement of the temporomandibular joint is a common complication that limits mandibular opening. A case of Arthrogryposis Multiplex Congenita with anterior open bite and limited maximal incisal opening is presented. Orthognathic surgery, consisting of segmental LeFort I osteotomy and bilateral sagittal split osteotomy, was performed successfully on this patient.